Provider Demographics
NPI:1295829646
Name:WOODARD, DANEEN (MD)
Entity Type:Individual
Prefix:
First Name:DANEEN
Middle Name:
Last Name:WOODARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-1631
Mailing Address - Country:US
Mailing Address - Phone:773-252-3122
Mailing Address - Fax:773-252-4538
Practice Address - Street 1:4401 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-1631
Practice Address - Country:US
Practice Address - Phone:773-252-3122
Practice Address - Fax:773-252-4538
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-098485207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
367830Medicare PIN
H25552Medicare UPIN