Healthcare Provider Details

I. General information

NPI: 1376592477
Provider Name (Legal Business Name): WALTER J WILLOUGHBY JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10105 BANBURRY CROSS DR STE 355
LAS VEGAS NV
89144-6649
US

IV. Provider business mailing address

10105 BANBURRY CROSS DR STE 355
LAS VEGAS NV
89144-6649
US

V. Phone/Fax

Practice location:
  • Phone: 702-409-3069
  • Fax: 702-473-1869
Mailing address:
  • Phone: 702-409-3069
  • Fax: 702-473-1869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number4004
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number4004
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number4004
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: