Healthcare Provider Details

I. General information

NPI: 1609894708
Provider Name (Legal Business Name): WILLIAM A WILLOUGHBY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 N COBB ST
MILLEDGEVILLE GA
31061-2343
US

IV. Provider business mailing address

1854 SHACKLEFORD CT SUITE 350
NORCROSS GA
30093-2954
US

V. Phone/Fax

Practice location:
  • Phone: 478-452-0524
  • Fax: 478-452-0525
Mailing address:
  • Phone: 770-688-3801
  • Fax: 770-237-6148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number038407
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: