Provider Demographics
NPI:1043283302
Name:WOODWORTH, STEPHEN R (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
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 1:2 IVY BROOK RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-6416
Mailing Address - Country:US
Mailing Address - Phone:203-922-9466
Mailing Address - Fax:203-922-9477
Practice Address - Street 1:2 IVY BROOK RD
Practice Address - Street 2:SUITE 205
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-6416
Practice Address - Country:US
Practice Address - Phone:203-922-9466
Practice Address - Fax:203-922-9477
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT044476207RC0000X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010044476CT01OtherANTHEM
CT001444760Medicaid
CT010044476CT01OtherANTHEM
CT001444760Medicaid