Provider Demographics
NPI:1891790507
Name:WILLOUGHBY, BRADLEY L (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:L
Last Name:WILLOUGHBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:577 MICHIGAN AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4911
Mailing Address - Country:US
Mailing Address - Phone:616-392-1816
Mailing Address - Fax:616-392-1292
Practice Address - Street 1:577 MICHIGAN AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4911
Practice Address - Country:US
Practice Address - Phone:616-392-1816
Practice Address - Fax:616-392-1292
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2015-07-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301052455208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1952507444OtherGROUP NPI
MI0P49290Medicare PIN
MIA03191Medicare UPIN