Provider Demographics
NPI:1518921725
Name:WOODWORTH, JOHN C (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:WOODWORTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3243
Mailing Address - Fax:616-252-0260
Practice Address - Street 1:8941 N RODGERS CT SE
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-8013
Practice Address - Country:US
Practice Address - Phone:616-252-5300
Practice Address - Fax:616-252-5390
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007070207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE26217Medicare UPIN
MIM53750039Medicare ID - Type Unspecified
MI01-5-41-0178-4OtherBCBS PIN
MI1518921725Medicaid