Provider Demographics
NPI:1164163135
Name:WOODARD, MARVIN
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:WOODARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 PURYEAR CIR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23661-2054
Mailing Address - Country:US
Mailing Address - Phone:757-401-7854
Mailing Address - Fax:
Practice Address - Street 1:2 PURYEAR CIR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23661-2054
Practice Address - Country:US
Practice Address - Phone:757-401-7854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver