Provider Demographics
NPI:1114902269
Name:WOODALL, TIMOTHY GERRARD (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:GERRARD
Last Name:WOODALL
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 1:1563 HEALTHCARE DR
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732
Mailing Address - Country:US
Mailing Address - Phone:803-329-6030
Mailing Address - Fax:803-329-6035
Practice Address - Street 1:1563 HEALTHCARE DR
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732
Practice Address - Country:US
Practice Address - Phone:803-329-6030
Practice Address - Fax:803-329-6035
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22243207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00162061OtherRAILROAD MEDICARE PIN
SCDC3336OtherRAILROAD MEDICARE
SC7992Medicare PIN
SCDC3336OtherRAILROAD MEDICARE