Provider Demographics
NPI:1508095977
Name:WOODERSON, KYLE C (DO)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:C
Last Name:WOODERSON
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Gender:M
Credentials:DO
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Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:918-786-7300
Mailing Address - Fax:918-786-7303
Practice Address - Street 1:601 E 13TH ST
Practice Address - Street 2:STE H
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2989
Practice Address - Country:US
Practice Address - Phone:918-786-7300
Practice Address - Fax:918-786-7303
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2017-04-05
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Provider Licenses
StateLicense IDTaxonomies
OK4824208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200254780AMedicaid
OK200505990OMedicaid
OK298030YKW9Medicare PIN
OK200254780AMedicaid