Basic Information
| Provider Information | |||||||||
| NPI: | 1982798310 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLSON | ||||||||
| FirstName: | TONY | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1707 COLE BLVD. | ||||||||
| Address2: | #100 | ||||||||
| City: | GOLDEN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037168018 | ||||||||
| FaxNumber: | 3037635495 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 W. COUNTY LINE RD. | ||||||||
| Address2: | #130 | ||||||||
| City: | HIGHLANDS RANCH | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037910418 | ||||||||
| FaxNumber: | 3037911849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 97817 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001860400 | 05 | FL | MEDICAID | 65779827 | 05 | CO | MEDICAID |