Provider Demographics
NPI:1477831295
Name:WOODALL, WALTON PRESTON JR (DO)
Entity Type:Individual
Prefix:
First Name:WALTON
Middle Name:PRESTON
Last Name:WOODALL
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:W.
Other - Middle Name:PRESTON
Other - Last Name:WOODALL
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:1102 N. TACOMA AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98403-2931
Mailing Address - Country:US
Mailing Address - Phone:253-274-0098
Mailing Address - Fax:
Practice Address - Street 1:1102 N. TACOMA AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98403-2931
Practice Address - Country:US
Practice Address - Phone:253-274-0098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-27
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00000992207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine