Provider Demographics
NPI:1467934455
Name:WOODBRIDGE, SHAHRZAD ROYA (DO)
Entity Type:Individual
Prefix:
First Name:SHAHRZAD
Middle Name:ROYA
Last Name:WOODBRIDGE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SHAHRZAD
Other - Middle Name:R
Other - Last Name:DOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:30 N 1900 E
Mailing Address - Street 2:SOM 1C026
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 N 1900 E
Practice Address - Street 2:SOM 1C026
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132
Practice Address - Country:US
Practice Address - Phone:801-581-2272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12404265-1204207P00000X
IDO-1794207P00000X
ORDO214548207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA201844875WAMedicaid