Provider Demographics
NPI:1962585570
Name:WILLOUGHBY, DARRYL ALAN (MD)
Entity type:Individual
Prefix:
First Name:DARRYL
Middle Name:ALAN
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: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 1:1513 S GRAND AVE # 208
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3021
Practice Address - Country:US
Practice Address - Phone:213-765-8088
Practice Address - Fax:310-329-3239
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54030208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A540300Medicaid
CA00A540300Medicaid
H07181Medicare UPIN
CAA54030AMedicare PIN