Healthcare Provider Details

I. General information

NPI: 1962425710
Provider Name (Legal Business Name): BRIAN J WILLOUGHBY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 E 3RD AVE STE 100
DENVER CO
80206-5248
US

IV. Provider business mailing address

3150 E 3RD AVE STE 100
DENVER CO
80206-5248
US

V. Phone/Fax

Practice location:
  • Phone: 303-320-5700
  • Fax: 303-322-6129
Mailing address:
  • Phone: 303-320-5700
  • Fax: 303-322-6129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number40115
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License NumberDR.0040115
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: