Provider Demographics
NPI:1164487260
Name:WOODALL, PHILIP M (DO)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:M
Last Name:WOODALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 LAKE BLUFF CV
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-5606
Mailing Address - Country:US
Mailing Address - Phone:512-246-6170
Mailing Address - Fax:512-246-6174
Practice Address - Street 1:1404 LAKE BLUFF CV
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-5606
Practice Address - Country:US
Practice Address - Phone:512-246-6170
Practice Address - Fax:512-246-6174
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXJ3658207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE66840Medicare UPIN
TX8F2701Medicare ID - Type UnspecifiedMEDICARE IND # WMSON CO
TX8F2713Medicare ID - Type UnspecifiedMEDICARE IND # TRAVIS CO