Basic Information
| Provider Information | |||||||||
| NPI: | 1770512311 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOODBURY | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705334786 | ||||||||
| Practice Location | |||||||||
| Address1: | 655 JESSE JEWELL PKWY SE STE B | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705327092 | ||||||||
| FaxNumber: | 7705360383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 05/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 27593 | SC | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 87424 | GA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | 27593 | SC | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XX0005X | 87424 | GA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 285800 | 01 | SC | MEDCOST | OTHER | 0003243833 | 05 | GA | MEDICAID | 275936 | 05 | SC | MEDICAID |