Provider Demographics
NPI:1447229174
Name:THOMAS W WOODWARD OD PC
Entity Type:Organization
Organization Name:THOMAS W WOODWARD OD PC
Other - Org Name:THOMAS W WOODWARD PC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:WHALEN
Authorized Official - Last Name:WOODWARD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-365-4531
Mailing Address - Street 1:PO BOX 687
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-0687
Mailing Address - Country:US
Mailing Address - Phone:208-365-4531
Mailing Address - Fax:
Practice Address - Street 1:304 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-3034
Practice Address - Country:US
Practice Address - Phone:208-365-4531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-0557152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807303600Medicaid
ID002451000Medicaid
ID1368592Medicare ID - Type UnspecifiedGROUP NUMBER MEDICARE
ID807303600Medicaid
ID002451000Medicaid
ID1590869Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE