1770725145 NPI number — DARRYL WILLOUGHBY M.D., INC

Table of content: (NPI 1770725145)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770725145 NPI number — DARRYL WILLOUGHBY M.D., INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DARRYL WILLOUGHBY M.D., INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770725145
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6620
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TORRANCE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90504-0620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-968-6012
Provider Business Mailing Address Fax Number:
310-329-3239

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1414 S GRAND AVE
Provider Second Line Business Practice Location Address:
SUITE 307
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90015-3067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-765-8088
Provider Business Practice Location Address Fax Number:
310-329-3239
Provider Enumeration Date:
04/01/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WILLOUGHBY
Authorized Official First Name:
DARRYL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
310-968-6012

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  A54030 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A540300 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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