Provider Demographics
NPI:1285662825
Name:WOODMAN, STEPHAN KERMIT (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHAN
Middle Name:KERMIT
Last Name:WOODMAN
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 1:2808 OLD FAIR RD
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-5220
Mailing Address - Country:US
Mailing Address - Phone:308-382-6856
Mailing Address - Fax:308-381-1560
Practice Address - Street 1:2620 W FAIDLEY AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4205
Practice Address - Country:US
Practice Address - Phone:308-382-6856
Practice Address - Fax:308-381-1560
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE127802085R0202X
KS04309872085R0202X
IA366192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE00422OtherBLUE CROSS BLUE SHIELD
NE00422OtherBLUE CROSS BLUE SHIELD
NE00422OtherBLUE CROSS BLUE SHIELD
NEE29172Medicare UPIN