Healthcare Provider Details

I. General information

NPI: 1871856740
Provider Name (Legal Business Name): MICHAEL PATRICK WOODBURY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2012
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 E DESERT INN RD STE 100
LAS VEGAS NV
89121
US

IV. Provider business mailing address

2800 E DESERT INN RD STE 100
LAS VEGAS NV
89121-3609
US

V. Phone/Fax

Practice location:
  • Phone: 702-731-1616
  • Fax: 702-734-4900
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5101020103
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberDO2289
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: