Provider Demographics
NPI:1235846528
Name:WOODFORK, ISSAC JAMES
Entity Type:Individual
Prefix:MR
First Name:ISSAC
Middle Name:JAMES
Last Name:WOODFORK
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 1:5157 WHALEY DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-8248
Mailing Address - Country:US
Mailing Address - Phone:937-750-6767
Mailing Address - Fax:
Practice Address - Street 1:5157 WHALEY DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-8248
Practice Address - Country:US
Practice Address - Phone:937-750-6767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH812808850Medicaid