Healthcare Provider Details

I. General information

NPI: 1295998193
Provider Name (Legal Business Name): ETHAN C WOODBURY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

OPC 41 BOX 15
APO AE
09461-9001
US

IV. Provider business mailing address

OPC 41 BOX 15
APO AE
09461-9001
US

V. Phone/Fax

Practice location:
  • Phone: 314-226-8205
  • Fax:
Mailing address:
  • Phone: 314-226-8205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number7024839-9934
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: