MEDICARE: KRISTIN WOODBURY D.O.

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	207Y00000X	Otolaryngology Physician	OS015105	PA
2	207YX0602X	Otolaryngic Allergy Physician	20A 11724	CA

General Provider Information

NPI Number	:	1861614067
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN WOODBURY D.O.

Provider Business Mailing Address
First Line	:	1710 PENNSYLVANIA AVE
Second Line	:	SUITE D
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-3589
Country	:	US
Telephone Number	:	707-432-2000
Fax Number	:	707-432-2001

Provider Business Practice Location Address
First Line	:	1710 PENNSYLVANIA AVE
Second Line	:	STE D
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-3549
Country	:	US
Telephone Number	:	707-432-2000
Fax Number	:	707-432-2001

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

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	07/21/2016

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