Healthcare Provider Details

I. General information

NPI: 1336209675
Provider Name (Legal Business Name): RICHARD HYRUM WOODLAND DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2006
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 N 2ND
CLINTON MO
64735-1192
US

IV. Provider business mailing address

1602 N 2ND
CLINTON MO
64735-1192
US

V. Phone/Fax

Practice location:
  • Phone: 660-885-8171
  • Fax:
Mailing address:
  • Phone: 660-890-8444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number2004034269
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: