Healthcare Provider Details

I. General information

NPI: 1447405576
Provider Name (Legal Business Name): WOODLEY DESIR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2008
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 S KOKE MILL RD
SPRINGFIELD IL
62711-9252
US

IV. Provider business mailing address

1301 S KOKE MILL RD
SPRINGFIELD IL
62711-9252
US

V. Phone/Fax

Practice location:
  • Phone: 217-547-9100
  • Fax: 217-547-9236
Mailing address:
  • Phone: 217-547-9100
  • Fax: 217-547-9236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number01084885A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number036.167421
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: