Provider Demographics
NPI:1902496011
Name:WOODSIDE, JULIANNE VAUGHN
Entity Type:Individual
Prefix:
First Name:JULIANNE
Middle Name:VAUGHN
Last Name:WOODSIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3217 COLORADO PL
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-2232
Mailing Address - Country:US
Mailing Address - Phone:714-322-9181
Mailing Address - Fax:
Practice Address - Street 1:3217 COLORADO PL
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-2232
Practice Address - Country:US
Practice Address - Phone:714-322-9181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT1530208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation