Healthcare Provider Details

I. General information

NPI: 1982798310
Provider Name (Legal Business Name): TONY L. WILLSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 COUNTY ROAD 210 W
ST JOHNS FL
32259-1183
US

IV. Provider business mailing address

PO BOX 746638
ATLANTA GA
30374-6638
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-4407
  • Fax: 904-390-7459
Mailing address:
  • Phone: 904-202-1032
  • Fax: 904-376-4107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0052091
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME97817
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: