Provider Demographics
NPI:1982798310
Name:WILLSON, TONY L (MD)
Entity type:Individual
Prefix:DR
First Name:TONY
Middle Name:L
Last Name:WILLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 746638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6638
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:1310 COUNTY ROAD 210 W
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-1183
Practice Address - Country:US
Practice Address - Phone:904-824-4407
Practice Address - Fax:904-390-7459
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CODR.0052091207Q00000X
FLME97817207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO65779827Medicaid
CO65779827Medicaid
CO65779827Medicaid
FLC0278YMedicare PIN