Provider Demographics
NPI:1801981451
Name:WILLOUGHBY, BRIAN G (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:G
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 1:1100 HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:HETTINGER
Mailing Address - State:ND
Mailing Address - Zip Code:58639-7533
Mailing Address - Country:US
Mailing Address - Phone:701-567-6130
Mailing Address - Fax:
Practice Address - Street 1:1000 HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:HETTINGER
Practice Address - State:ND
Practice Address - Zip Code:58639
Practice Address - Country:US
Practice Address - Phone:701-567-4561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5103207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND123993OtherWORKER'S COMP
SD7776070Medicaid
ND14656Medicaid
WA3018140Medicaid
MN7088230-00Medicaid
25451OtherSIOUX VALLEY
IA0568253Medicaid
10781OtherND BLUE CROSS/BLUE SHIELD
NE45034068812Medicaid
NDN10781Medicare PIN
SD7776070Medicaid
MN7088230-00Medicaid