Provider Demographics
NPI:1225157878
Name:WOODALL, GREGORY ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALAN
Last Name:WOODALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 N MAIN ST
Mailing Address - Street 2:P.O. BOX 336
Mailing Address - City:HOMER
Mailing Address - State:LA
Mailing Address - Zip Code:71040-3846
Mailing Address - Country:US
Mailing Address - Phone:318-927-3976
Mailing Address - Fax:318-927-9916
Practice Address - Street 1:621 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:LA
Practice Address - Zip Code:71040-3846
Practice Address - Country:US
Practice Address - Phone:318-927-3976
Practice Address - Fax:318-927-9916
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA973-258T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1987859Medicaid
LAT69507Medicare UPIN
LA1987859Medicaid