Provider Demographics
NPI:1235493099
Name:WOODBURY, DERREK
Entity Type:Individual
Prefix:
First Name:DERREK
Middle Name:
Last Name:WOODBURY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 NE CUSHING DR STE 100
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3887
Mailing Address - Country:US
Mailing Address - Phone:541-388-2333
Mailing Address - Fax:541-388-0930
Practice Address - Street 1:1303 NE CUSHING DR STE 100
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3887
Practice Address - Country:US
Practice Address - Phone:541-388-2333
Practice Address - Fax:541-388-0930
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020102207X00000X, 207XX0801X
ORDO190678207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma