Provider Demographics
NPI:1609878115
Name:WOODBURY, THOMAS ALLEN (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ALLEN
Last Name:WOODBURY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9089 BASELINE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-1295
Mailing Address - Country:US
Mailing Address - Phone:909-941-9927
Mailing Address - Fax:909-941-9027
Practice Address - Street 1:9089 BASELINE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1295
Practice Address - Country:US
Practice Address - Phone:909-941-9927
Practice Address - Fax:909-941-9027
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5929207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX59290Medicaid
CA00AX59290Medicaid
CA020A59291Medicare ID - Type Unspecified