Provider Demographics
NPI:1083371314
Name:WOODARD, MICHAEL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WOODARD
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4178 32ND ST APT 8
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-2067
Mailing Address - Country:US
Mailing Address - Phone:805-757-3744
Mailing Address - Fax:
Practice Address - Street 1:585 SATURN BLVD STE A
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-4721
Practice Address - Country:US
Practice Address - Phone:619-591-1190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA301372225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist