Provider Demographics
NPI:1013034628
Name:FIVE J WOODALL MEDICAL DIRECTOR
Entity Type:Organization
Organization Name:FIVE J WOODALL MEDICAL DIRECTOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:WOODALL
Authorized Official - Suffix:
Authorized Official - Credentials:(MD)
Authorized Official - Phone:765-642-8446
Mailing Address - Street 1:299 E 360 N
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46012-9659
Mailing Address - Country:US
Mailing Address - Phone:765-642-8446
Mailing Address - Fax:765-642-7934
Practice Address - Street 1:299 E 360 N
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46012-9659
Practice Address - Country:US
Practice Address - Phone:765-642-8446
Practice Address - Fax:765-642-7934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01022907A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100171870AMedicaid
IN505830AMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER