Provider Demographics
NPI:1659631984
Name:WILLOUGHBY, JULIAN DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JULIAN
Middle Name:DAVID
Last Name:WILLOUGHBY
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 1:225 BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3109
Mailing Address - Country:US
Mailing Address - Phone:704-376-1605
Mailing Address - Fax:704-335-8448
Practice Address - Street 1:110 LAKE CONCORD RD NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2918
Practice Address - Country:US
Practice Address - Phone:704-792-2672
Practice Address - Fax:704-792-2674
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2017-01920208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1659631984Medicaid