Healthcare Provider Details

I. General information

NPI: 1396015095
Provider Name (Legal Business Name): JAMES W WILLOUGHBY II DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24-26 S MAIN ST STE A
LIBERTY MO
64069
US

IV. Provider business mailing address

24-26 S MAIN ST
LIBERTY MO
64069
US

V. Phone/Fax

Practice location:
  • Phone: 816-781-0902
  • Fax:
Mailing address:
  • Phone: 816-781-0902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KI0005X
TaxonomyClinical & Laboratory Immunology (Allergy & Immunology) Physician
License Number37014
License Number StateMO

VIII. Authorized Official

Name: DR. JAMES W WILLOUGHBY II
Title or Position: OWNER
Credential: DO
Phone: 816-781-0902