Provider Demographics
NPI:1396015095
Name:JAMES W WILLOUGHBY II DO PC
Entity Type:Organization
Organization Name:JAMES W WILLOUGHBY II DO PC
Other - Org Name:LIBERTY HOLISTIC MEDICINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:WILLOUGHBY
Authorized Official - Suffix:II
Authorized Official - Credentials:DO
Authorized Official - Phone:816-781-0902
Mailing Address - Street 1:24-26 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64069
Mailing Address - Country:US
Mailing Address - Phone:816-781-0902
Mailing Address - Fax:
Practice Address - Street 1:24-26 S MAIN ST
Practice Address - Street 2:STE A
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64069
Practice Address - Country:US
Practice Address - Phone:816-781-0902
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO37014207KI0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory ImmunologyGroup - Single Specialty