Provider Demographics
NPI:1457578536
Name:WILLOUGHBY, LINDA A (MD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:A
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 1:3993 SAINT CLAIR CT NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-1845
Mailing Address - Country:US
Mailing Address - Phone:678-689-3494
Mailing Address - Fax:
Practice Address - Street 1:2200 CENTURY PKWY NE
Practice Address - Street 2:SUITE 600
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3154
Practice Address - Country:US
Practice Address - Phone:404-633-4838
Practice Address - Fax:404-633-4839
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10666207R00000X, 2083X0100X
GA0272612083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC106664Medicaid
SCSC89296067Medicare PIN
SC106664Medicaid
GA511G700201Medicare PIN
GA202I114396Medicare UPIN