Provider Demographics
NPI:1366528911
Name:WOODBURN, SCOTT EDWARD (DPM)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:EDWARD
Last Name:WOODBURN
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 1:1 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014
Mailing Address - Country:US
Mailing Address - Phone:410-803-0788
Mailing Address - Fax:410-803-1859
Practice Address - Street 1:6569 NORTH CHARLES STREET
Practice Address - Street 2:SUITE 702
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204
Practice Address - Country:US
Practice Address - Phone:410-828-5420
Practice Address - Fax:410-821-5833
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01023213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH792OtherBLUE CROSS
MDE602OtherNATIONAL CAP BLUE
MD288268000Medicaid
MDE602OtherNATIONAL CAP BLUE
MD288268000Medicaid
MDH792S987Medicare ID - Type Unspecified
MD0734830006Medicare NSC