Provider Demographics
NPI:1588667182
Name:WOODALL, BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:WOODALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1610
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-1610
Mailing Address - Country:US
Mailing Address - Phone:903-887-1011
Mailing Address - Fax:
Practice Address - Street 1:801 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GUN BARREL CITY
Practice Address - State:TX
Practice Address - Zip Code:75156
Practice Address - Country:US
Practice Address - Phone:903-887-1011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9450207Q00000X
TXP3269207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010152435OtherREGENCE BS OF ID
WA0204370OtherWA LABOR & INDUSTRIES
WA8439838Medicaid
TX8DK990OtherBCBS OF TX
ID76273OtherBLUE CROSS OF ID
ID807296400Medicaid
TX302470501Medicaid
601417300OtherDEEIOC
IDE58975Medicare UPIN
ID1373881Medicare Oscar/Certification
IDCS6290Medicare Oscar/Certification
ID1131974Medicare PIN
601417300OtherDEEIOC
TX302470501Medicaid
ID807296400Medicaid
TXTXB158395Medicare PIN