Provider Demographics
NPI:1174667836
Name:WOODHAM, PHILIP G
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:G
Last Name:WOODHAM
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 1:452 OLD HOOK RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1381
Mailing Address - Country:US
Mailing Address - Phone:201-666-3900
Mailing Address - Fax:201-261-0505
Practice Address - Street 1:20 PROSPECT AVE
Practice Address - Street 2:SUITE 715
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1997
Practice Address - Country:US
Practice Address - Phone:201-881-0721
Practice Address - Fax:201-881-0725
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA67550207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ065943Medicare PIN
NJ038046RBMMedicare PIN
NJX83358Medicare UPIN