Provider Demographics
NPI:1548210339
Name:WOODARD, QEENA C (DPM)
Entity Type:Individual
Prefix:DR
First Name:QEENA
Middle Name:C
Last Name:WOODARD
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 W NORTH AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-1174
Mailing Address - Country:US
Mailing Address - Phone:312-808-0018
Mailing Address - Fax:312-808-0037
Practice Address - Street 1:711 W NORTH AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-1174
Practice Address - Country:US
Practice Address - Phone:312-808-0018
Practice Address - Fax:312-808-0037
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-005278213E00000X
IN07001092A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001633214OtherBCBS
IL0001633214OtherBCBS