Provider Demographics
NPI:1629213780
Name:WOOLLEY, MARK EDWIN (DPM)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EDWIN
Last Name:WOOLLEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 CHAMBERS ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4519
Mailing Address - Country:US
Mailing Address - Phone:801-627-2122
Mailing Address - Fax:801-627-2125
Practice Address - Street 1:955 CHAMBERS ST STE 200
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4519
Practice Address - Country:US
Practice Address - Phone:801-409-2100
Practice Address - Fax:801-475-6169
Is Sole Proprietor?:No
Enumeration Date:2008-12-03
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0718213ES0103X
TX1946213ES0103X
UT7081436-0501213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTZ139339Medicare UPIN