Provider Demographics
NPI:1164424701
Name:WOOLLEN, TODD A (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:A
Last Name:WOOLLEN
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 1:2201 N BROADWELL AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-2153
Mailing Address - Country:US
Mailing Address - Phone:308-382-3660
Mailing Address - Fax:308-389-5111
Practice Address - Street 1:2201 N BROADWELL AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-2153
Practice Address - Country:US
Practice Address - Phone:308-382-3660
Practice Address - Fax:308-389-5111
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA34701207Q00000X
NE21191207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0270801Medicaid
IA30555OtherWELLMARK BC/BS
IA0270801Medicaid
IAI10339Medicare ID - Type Unspecified