Provider Demographics
NPI:1235336421
Name:WILLOUGHBY, CHANNING DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHANNING
Middle Name:DALE
Last Name:WILLOUGHBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 421718
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29442-4203
Mailing Address - Country:US
Mailing Address - Phone:843-652-8226
Mailing Address - Fax:
Practice Address - Street 1:4040 HIGHWAY 17
Practice Address - Street 2:SUITE206
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-5098
Practice Address - Country:US
Practice Address - Phone:843-652-8260
Practice Address - Fax:843-652-8269
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC33509208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC33509OtherSTATE MEDICAL LICENSE