Provider Demographics
NPI:1861029019
Name:WOODWORTH, TYLER T (MD)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:T
Last Name:WOODWORTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4530 E MUIRWOOD DR STE 110
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7693
Mailing Address - Country:US
Mailing Address - Phone:480-763-5808
Mailing Address - Fax:480-759-0647
Practice Address - Street 1:4530 E MUIRWOOD DR STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7693
Practice Address - Country:US
Practice Address - Phone:480-763-5808
Practice Address - Fax:480-759-0647
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12409924-1205208100000X
AZ72028208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ206392Medicaid