Provider Demographics
NPI:1770572893
Name:WOODBURY, WAYNE M (MD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:M
Last Name:WOODBURY
Suffix:
Gender:
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 632476
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-2476
Mailing Address - Country:US
Mailing Address - Phone:423-794-5580
Mailing Address - Fax:423-232-8561
Practice Address - Street 1:316 MARKETPLACE DR STE 20
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2596
Practice Address - Country:US
Practice Address - Phone:423-794-5580
Practice Address - Fax:423-232-8561
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042978208100000X
UT8397828-12052081P2900X
TN246422081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA552387OtherWELLCARE MEDICAID & MEDICARE
SCG42978Medicaid
TNQ010272Medicaid
GA000729385CMedicaid
01352928OtherAMERIGROUP
GA000729385AMedicaid
GA000729385DMedicaid
GAP00795760OtherRR MEDICARE
SCG42978Medicaid
GA000729385CMedicaid