MEDICARE: MARK EDWIN WOOLLEY DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	0718	AZ
2	213ES0103X	Foot & Ankle Surgery Podiatrist	1946	TX
3	213ES0103X	Foot & Ankle Surgery Podiatrist	7081436-0501	UT

General Provider Information

NPI Number	:	1629213780
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK EDWIN WOOLLEY DPM

Provider Business Mailing Address
First Line	:	955 CHAMBERS ST STE 200
Second Line	:
City	:	SOUTH OGDEN
State	:	UT
Zip	:	84403-4519
Country	:	US
Telephone Number	:	801-627-2122
Fax Number	:	801-627-2125

Provider Business Practice Location Address
First Line	:	955 CHAMBERS ST STE 200
Second Line	:
City	:	SOUTH OGDEN
State	:	UT
Zip	:	84403-4519
Country	:	US
Telephone Number	:	801-409-2100
Fax Number	:	801-475-6169

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/03/2008
Last Update Date	:	03/28/2019

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Directions to “ MARK EDWIN WOOLLEY DPM” Practice Location

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