Healthcare Provider Details

I. General information

NPI: 1154313591
Provider Name (Legal Business Name): MICHAEL J WOODBURY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 12/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3002 N GERMANTOWN RD
BARTLETT TN
38133-4023
US

IV. Provider business mailing address

3002 N GERMANTOWN RD
BARTLETT TN
38133-4023
US

V. Phone/Fax

Practice location:
  • Phone: 901-861-2234
  • Fax:
Mailing address:
  • Phone: 901-861-2234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberFSJ499
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: