Provider Demographics
NPI:1962425710
Name:WILLOUGHBY, BRIAN J (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
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 1:3150 E 3RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-5248
Mailing Address - Country:US
Mailing Address - Phone:303-320-5700
Mailing Address - Fax:303-322-6129
Practice Address - Street 1:3150 E 3RD AVE STE 100
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-5248
Practice Address - Country:US
Practice Address - Phone:303-320-5700
Practice Address - Fax:303-322-6129
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40115207W00000X
CODR.0040115207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO28836235Medicaid
CO60008067Medicaid
COH14511Medicare UPIN
COC463778Medicare PIN