Provider Demographics
NPI:1508977349
Name:WOODRUFF, MARY JANE
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JANE
Last Name:WOODRUFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 E FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-4750
Mailing Address - Country:US
Mailing Address - Phone:951-332-9792
Mailing Address - Fax:951-332-9818
Practice Address - Street 1:1919 E FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544-4750
Practice Address - Country:US
Practice Address - Phone:951-332-9792
Practice Address - Fax:951-332-9818
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASL004327156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician