Provider Demographics
NPI:1093719569
Name:WOODSON, CHERYL E (MD)
Entity Type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:E
Last Name:WOODSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25020 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1250
Mailing Address - Country:US
Mailing Address - Phone:708-709-9200
Mailing Address - Fax:773-767-3944
Practice Address - Street 1:316 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-1770
Practice Address - Country:US
Practice Address - Phone:708-709-9200
Practice Address - Fax:773-767-3944
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-12
Last Update Date:2010-01-22
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
IL036076317174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036076317Medicaid
ILE18814Medicare UPIN
IL609070Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER