Provider Demographics
NPI:1598103806
Name:WOODALL, NICHOLAS JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JAMES
Last Name:WOODALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:46135-1850
Mailing Address - Country:US
Mailing Address - Phone:765-653-5896
Mailing Address - Fax:765-653-4554
Practice Address - Street 1:814 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-1850
Practice Address - Country:US
Practice Address - Phone:765-653-5896
Practice Address - Fax:765-653-4554
Is Sole Proprietor?:No
Enumeration Date:2013-06-08
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003791A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201169700AMedicaid