Provider Demographics
NPI:1366499782
Name:WOODWORTH, RONALD S (DO)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:S
Last Name:WOODWORTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 HOSPITAL DR STE 300
Mailing Address - Street 2:PO BOX 1432
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-5018
Mailing Address - Country:US
Mailing Address - Phone:802-447-1564
Mailing Address - Fax:802-447-3346
Practice Address - Street 1:140 HOSPITAL DR
Practice Address - Street 2:SUITE 300
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-5009
Practice Address - Country:US
Practice Address - Phone:802-447-1564
Practice Address - Fax:802-447-3346
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0320000265207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0005198Medicaid
VT5198OtherBCBS VT
E33040Medicare UPIN
VTVT5198Medicare ID - Type Unspecified