Provider Demographics
NPI:1447231782
Name:WOODARD, DAVID OWEN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:OWEN
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 1:25 N WINFIELD RD
Mailing Address - Street 2:STE 410
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190
Mailing Address - Country:US
Mailing Address - Phone:630-665-2101
Mailing Address - Fax:630-665-3828
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:STE 410
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190
Practice Address - Country:US
Practice Address - Phone:630-665-2101
Practice Address - Fax:630-665-3828
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2201796OtherBC
IL0360801361Medicaid
ILL61194Medicare ID - Type Unspecified
IL0360801361Medicaid