Healthcare Provider Details

I. General information

NPI: 1477784791
Provider Name (Legal Business Name): C.TODD WOOLLEY MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 08/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 NW LOVEJOY ST STE 401
PORTLAND OR
97210-5102
US

IV. Provider business mailing address

2222 NW LOVEJOY ST STE 401
PORTLAND OR
97210-5102
US

V. Phone/Fax

Practice location:
  • Phone: 503-274-4865
  • Fax: 503-274-4989
Mailing address:
  • Phone: 503-274-4865
  • Fax: 503-274-4989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberMD23565
License Number StateOR

VIII. Authorized Official

Name: DR. CHARLES T WOOLLEY
Title or Position: PRESIDENT
Credential: MD
Phone: 503-274-4865