Healthcare Provider Details

I. General information

NPI: 1750476016
Provider Name (Legal Business Name): DEREK A WOESSNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2257 TAYLOR RD
MONTGOMERY AL
36117-7790
US

IV. Provider business mailing address

PO BOX 370
FORTSON GA
31808-0370
US

V. Phone/Fax

Practice location:
  • Phone: 334-245-6605
  • Fax: 334-821-3191
Mailing address:
  • Phone: 706-494-3072
  • Fax: 706-494-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number051194
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD.28193
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: