Provider Demographics
NPI:1295998193
Name:WOODBURY, ETHAN C (OD)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:C
Last Name:WOODBURY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1599 J ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS AFB
Mailing Address - State:ND
Mailing Address - Zip Code:58205-6306
Mailing Address - Country:US
Mailing Address - Phone:701-747-5515
Mailing Address - Fax:
Practice Address - Street 1:1515 TRUEMPER ST
Practice Address - Street 2:
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-5583
Practice Address - Country:US
Practice Address - Phone:210-671-9550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7024839-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist