Provider Demographics
NPI:1144753492
Name:WOOLSEY, CREIGHTON (DPM)
Entity type:Individual
Prefix:
First Name:CREIGHTON
Middle Name:
Last Name:WOOLSEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 W PARKVIEW ST STE 2J
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-8598
Mailing Address - Country:US
Mailing Address - Phone:417-328-7000
Mailing Address - Fax:417-328-1142
Practice Address - Street 1:1155 W PARKVIEW ST STE 2J
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-8598
Practice Address - Country:US
Practice Address - Phone:417-328-7000
Practice Address - Fax:417-328-1142
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020015348213ES0103X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery