Healthcare Provider Details

I. General information

NPI: 1568048502
Provider Name (Legal Business Name): KEVIN EDWARD WOODHAMS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2021
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 W PUEBLO ST
RENO NV
89509-2845
US

IV. Provider business mailing address

130 W PUEBLO ST
RENO NV
89509-2845
US

V. Phone/Fax

Practice location:
  • Phone: 209-470-5439
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDR.0076789
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: