Provider Demographics
NPI:1518943943
Name:WILLIFORD, PHILLIP MABON (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:MABON
Last Name:WILLIFORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-6761
Practice Address - Street 1:4618 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-3520
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-6761
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26483207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
88074OtherBCBS
5552OtherPARTNERS
VA5940478Medicaid
SCN26483Medicaid
WV2005036000Medicaid
4671710OtherAETNA
70016802OtherRR MEDICARE
NC8988074Medicaid
64002OtherMEDCOST
WV2005036000Medicaid
SCN26483Medicaid