Provider Demographics
NPI:1861614067
Name:WOODBURY, KRISTIN (DO)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:WOODBURY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-3589
Mailing Address - Country:US
Mailing Address - Phone:707-432-2000
Mailing Address - Fax:707-432-2001
Practice Address - Street 1:1710 PENNSYLVANIA AVE
Practice Address - Street 2:STE D
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3549
Practice Address - Country:US
Practice Address - Phone:707-432-2000
Practice Address - Fax:707-432-2001
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS015105207Y00000X
CA20A 11724207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology