=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821154881
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENT L WOODBURY DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6700 N FIRST ST SUITE 105
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-431-0757
-----------------------------------------------------
Fax | 559-431-0758
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6700 N FIRST ST SUITE 105
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-431-0757
-----------------------------------------------------
Fax | 559-431-0758
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | E2222
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------