MEDICARE: DR. KELLY H WOODWARD I D.O., M.P.H.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	9693614-1204	UT
2	2083P0901X	Public Health & General Preventive Medicine Physician	9693614-1204	UT

General Provider Information

NPI Number	:	1548243645
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY H WOODWARD I D.O., M.P.H.

Provider Business Mailing Address
First Line	:	7165 CANYON DR
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-5382
Country	:	US
Telephone Number	:	703-907-9716
Fax Number	:

Provider Business Practice Location Address
First Line	:	5532 LILLEHAMMER LN STE 102
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-6078
Country	:	US
Telephone Number	:	435-659-7633
Fax Number	:	971-397-0394

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	07/09/2025

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