Provider Demographics
NPI: | 1316198856 |
---|---|
Name: | WOODBURY, HOWARD P |
Entity Type: | Individual |
Prefix: | |
First Name: | HOWARD |
Middle Name: | P |
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: | 2500 NEUDORF RD STE A |
Mailing Address - Street 2: | |
Mailing Address - City: | CLEMMONS |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 27012-8944 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 336-766-7816 |
Mailing Address - Fax: | 336-766-7881 |
Practice Address - Street 1: | 2500 NEUDORF RD STE A |
Practice Address - Street 2: | |
Practice Address - City: | CLEMMONS |
Practice Address - State: | NC |
Practice Address - Zip Code: | 27012-8944 |
Practice Address - Country: | US |
Practice Address - Phone: | 336-766-7816 |
Practice Address - Fax: | 336-766-7881 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2008-10-02 |
Last Update Date: | 2008-10-02 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 225000000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 225000000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Orthotic Fitter |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | 7795189 | Medicaid | |
NC | 7704197 | Medicaid | |
NC | 807510 | Other | BLUE MEDICARE |
NC | 1028122 | Other | UNITED HEALTHCARE |
046VK | Other | BLUE CROSS BLUE SHIELD | |
NC | 7704197 | Medicaid |