Healthcare Provider Details

I. General information

NPI: 1851696520
Provider Name (Legal Business Name): ADAM MICHAEL WOODYARD MS, RDN, CSSD, LD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2011
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234-4504
US

IV. Provider business mailing address

3551 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234-4504
US

V. Phone/Fax

Practice location:
  • Phone: 210-539-9582
  • Fax:
Mailing address:
  • Phone: 210-539-9582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number82392
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: