Provider Demographics
NPI:1013989193
Name:WILLOUGHBY, TAMARA (MD)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:WILLOUGHBY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7007
Mailing Address - Country:US
Mailing Address - Phone:207-795-5011
Mailing Address - Fax:207-753-7201
Practice Address - Street 1:300 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7007
Practice Address - Country:US
Practice Address - Phone:207-795-5011
Practice Address - Fax:207-753-7201
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015264207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MECA0584Medicare PIN
MECA0064Medicare PIN
MEMM792701Medicare PIN
MEMM792703Medicare PIN