Provider Demographics
NPI:1306182894
Name:WOODY, RYAN MATTHEW (IDC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MATTHEW
Last Name:WOODY
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 BROAD STREET EXT
Mailing Address - Street 2:APT B3-4
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3745
Mailing Address - Country:US
Mailing Address - Phone:979-236-9081
Mailing Address - Fax:
Practice Address - Street 1:25 BROAD STREET EXT
Practice Address - Street 2:APT B3-4
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-3745
Practice Address - Country:US
Practice Address - Phone:979-236-9081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-02
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman