Provider Demographics
NPI:1558367763
Name:WOODBURY, GEORGE R
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:R
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 1:8143 WALNUT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-7270
Mailing Address - Country:US
Mailing Address - Phone:901-753-0168
Mailing Address - Fax:901-754-4946
Practice Address - Street 1:8143 WALNUT GROVE RD
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-7270
Practice Address - Country:US
Practice Address - Phone:901-753-0168
Practice Address - Fax:901-754-4946
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD-18701174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TND16813Medicare UPIN
TN3051299Medicare ID - Type Unspecified