Provider Demographics
NPI:1659375301
Name:WILLOUGHBY, COLE BRADFORD (MD)
Entity Type:Individual
Prefix:DR
First Name:COLE
Middle Name:BRADFORD
Last Name:WILLOUGHBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:319 F ST
Mailing Address - Street 2:STE 102
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-2666
Mailing Address - Country:US
Mailing Address - Phone:619-476-1200
Mailing Address - Fax:619-420-7849
Practice Address - Street 1:319 F ST
Practice Address - Street 2:STE 102
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-2666
Practice Address - Country:US
Practice Address - Phone:619-476-1200
Practice Address - Fax:619-420-7849
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC36597207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C365970Medicaid
CAA87865Medicare UPIN
CAWC36597BMedicare ID - Type Unspecified