Individual
DR. PHILLIP MABON WILLIFORD
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
4618 COUNTRY CLUB RD, WINSTON SALEM, NC 27104-3520
(336) 716-2255
(336) 716-6761
Mailing address
PO BOX 344, WINSTON SALEM, NC 27102-0344
(336) 716-2255
(336) 716-6761
Taxonomy
Speciality
Code
Description
License number
State
207ND0101X
MOHS-Micrographic Surgery Physician
Primary
26483
NC
207NS0135X
Procedural Dermatology Physician
26483
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2005036000
—
WV
01
—
4671710
AETNA
—
01
—
5552
PARTNERS
—
05
—
5940478
—
VA
01
—
64002
MEDCOST
—
01
—
70016802
RR MEDICARE
—
01
—
88074
BCBS
—
05
—
8988074
—
NC
05
—
N26483
—
SC
Enumeration date
12/19/2005
Last updated
11/15/2010
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