Provider Demographics
NPI:1821154881
Name:WOODBURY, BRENT L (DPM)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:L
Last Name:WOODBURY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6700 N FIRST ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710
Mailing Address - Country:US
Mailing Address - Phone:559-431-0757
Mailing Address - Fax:559-431-0758
Practice Address - Street 1:6700 N FIRST ST
Practice Address - Street 2:SUITE 105
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710
Practice Address - Country:US
Practice Address - Phone:559-431-0757
Practice Address - Fax:559-431-0758
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2222213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E22220Medicaid
T11233Medicare UPIN
CA000E22220Medicaid