MEDICARE: VICKIE WILLOUGHBY DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZF0201X	Forensic Pathology Physician	N2884	TX

General Provider Information

NPI Number	:	1255714911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICKIE WILLOUGHBY DO

Provider Business Mailing Address
First Line	:	PO BOX 1748
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78767-1748
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1213 SABINE ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78701-1917
Country	:	US
Telephone Number	:	512-854-9599
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2015
Last Update Date	:	06/30/2015

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Directions to “ VICKIE WILLOUGHBY DO” Practice Location

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