Provider Demographics
NPI:1962480996
Name:WOOLLEY, CHARLES TODD (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:TODD
Last Name:WOOLLEY
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 1:2222 NW LOVEJOY
Mailing Address - Street 2:SUITE 401
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210
Mailing Address - Country:US
Mailing Address - Phone:503-274-4865
Mailing Address - Fax:503-274-4989
Practice Address - Street 1:2222 NW LOVEJOY
Practice Address - Street 2:SUITE 401
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210
Practice Address - Country:US
Practice Address - Phone:503-274-4865
Practice Address - Fax:503-274-4989
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23565174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286747Medicaid
ORH27437Medicare UPIN
R112766Medicare PIN
ORR112766Medicare PIN
OR286747Medicaid