Provider Demographics
NPI:1366499451
Name:CLUM, WOODWORTH B (MD)
Entity Type:Individual
Prefix:
First Name:WOODWORTH
Middle Name:B
Last Name:CLUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BERNIE
Other - Middle Name:
Other - Last Name:CLUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 11719
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-1719
Mailing Address - Country:US
Mailing Address - Phone:800-592-6421
Mailing Address - Fax:
Practice Address - Street 1:75 NIELSON STREET
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076
Practice Address - Country:US
Practice Address - Phone:408-724-4741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64973207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G649730Medicaid
CA00G649731Medicare PIN
CA00G649730Medicare PIN
F16073Medicare UPIN