Provider Demographics
NPI:1114111440
Name:GERALD R WOODARD DO PA
Entity Type:Organization
Organization Name:GERALD R WOODARD DO PA
Other - Org Name:SHORES MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:WOODARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-767-9544
Mailing Address - Street 1:3512 S ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:32118-7639
Mailing Address - Country:US
Mailing Address - Phone:386-767-9544
Mailing Address - Fax:386-756-0501
Practice Address - Street 1:3512 S ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH SHORES
Practice Address - State:FL
Practice Address - Zip Code:32118-7639
Practice Address - Country:US
Practice Address - Phone:386-767-9544
Practice Address - Fax:386-756-0501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4717207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6813Medicare PIN