Provider Demographics
NPI:1518965862
Name:WOODWARD, MARK R (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:WOODWARD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 US 31W BYP
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-2418
Mailing Address - Country:US
Mailing Address - Phone:270-781-5644
Mailing Address - Fax:270-781-4401
Practice Address - Street 1:1048 US 31W BYP
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-2418
Practice Address - Country:US
Practice Address - Phone:270-781-5644
Practice Address - Fax:270-781-4401
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4006111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000050377OtherANTHEM BLUE CROSS BLUE SH
KY85000115Medicaid
KY000000050377OtherANTHEM BLUE CROSS BLUE SH
KYT54511Medicare UPIN