Provider Demographics
NPI:1710133491
Name:WOODSON, BRENT ALLEN (DO)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:ALLEN
Last Name:WOODSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1727
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-1727
Mailing Address - Country:US
Mailing Address - Phone:970-263-2680
Mailing Address - Fax:970-263-2684
Practice Address - Street 1:2373 G RD STE 160
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-1003
Practice Address - Country:US
Practice Address - Phone:970-263-2680
Practice Address - Fax:970-263-2684
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-13
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO54118207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO38758270Medicaid