Provider Demographics
NPI:1770725145
Name:DARRYL WILLOUGHBY M.D., INC
Entity type:Organization
Organization Name:DARRYL WILLOUGHBY M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILLOUGHBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-968-6012
Mailing Address - Street 1:PO BOX 6620
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-0620
Mailing Address - Country:US
Mailing Address - Phone:310-968-6012
Mailing Address - Fax:310-329-3239
Practice Address - Street 1:1414 S GRAND AVE
Practice Address - Street 2:SUITE 307
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3067
Practice Address - Country:US
Practice Address - Phone:213-765-8088
Practice Address - Fax:310-329-3239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54030207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A540300Medicaid
H07181Medicare UPIN
CA00A540300Medicaid
A54030AMedicare PIN