Provider Demographics
NPI:1346274800
Name:WOODARD, RUSSELL L (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:L
Last Name:WOODARD
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 1:8122 DATAPOINT DR STE 320
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3264
Mailing Address - Country:US
Mailing Address - Phone:210-614-5113
Mailing Address - Fax:210-616-0024
Practice Address - Street 1:8122 DATAPOINT DR STE 320
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3264
Practice Address - Country:US
Practice Address - Phone:210-614-5113
Practice Address - Fax:210-616-0024
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5065174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103615401Medicaid
TX834856Medicare ID - Type Unspecified
TX103615401Medicaid