Provider Demographics
NPI:1154313591
Name:WOODBURY, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:WOODBURY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3002 N GERMANTOWN RD
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38133-4023
Mailing Address - Country:US
Mailing Address - Phone:901-861-2234
Mailing Address - Fax:
Practice Address - Street 1:3002 N GERMANTOWN RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133-4023
Practice Address - Country:US
Practice Address - Phone:901-861-2234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNFSJ499207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR070007680OtherRR MEDICARE
TN070011483OtherRR MEDICARE
AR126719001Medicaid
TNF5J499Medicare UPIN
ARF85962Medicare UPIN
TN070011483OtherRR MEDICARE
AR5J499Medicare ID - Type Unspecified