Basic Information
| Provider Information | |||||||||
| NPI: | 1497047096 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLARD | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 E CAMELBACK RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850182327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029331813 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 325 ROUTE 70 E | ||||||||
| Address2: | |||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563098508 | ||||||||
| FaxNumber: | 8563098556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085P0229X | C1-0012759 | DE | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | BP10040578 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085P0229X | 53868 | AZ | Y | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085P0229X | 25MA10383700 | NJ | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085P0229X | MD464892 | PA | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
ID Information
| ID | Type | State | Issuer | Description | 588799 | 05 | AZ | MEDICAID |