Provider Demographics
NPI:1366494858
Name:WOODSON, BEVERLY TUCKER (MD)
Entity Type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:TUCKER
Last Name:WOODSON
Suffix:
Gender:M
Credentials:MD
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Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPARTMENT OF OTOLARYNGOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-5580
Mailing Address - Fax:414-805-8324
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPARTMENT OF OTOLARYNGOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-5580
Practice Address - Fax:414-805-8324
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI29400207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
002000139OtherHUMANA
WI1366494858Medicaid
040006716OtherRAILROAD MEDICARE
WI31413100Medicaid
B85365Medicare UPIN
WI1366494858Medicaid
WI31413100Medicaid