Provider Demographics
NPI:1770512311
Name:WOODBURY, DAVID M (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:WOODBURY
Suffix:
Gender:M
Credentials:MD
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 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:655 JESSE JEWELL PKWY SE STE B
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3854
Practice Address - Country:US
Practice Address - Phone:770-532-7092
Practice Address - Fax:770-536-0383
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA87424207XX0005X, 207X00000X
SC27593207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC285800OtherMEDCOST
GA0003243833Medicaid
SC275936Medicaid
SC275936Medicaid
SC8310Medicare ID - Type UnspecifiedGROUP#