Provider Demographics
NPI:1619916723
Name:JUSTICE, WOODROW WILSON (OD)
Entity Type:Individual
Prefix:DR
First Name:WOODROW
Middle Name:WILSON
Last Name:JUSTICE
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:PO BOX 524
Mailing Address - Street 2:215 S. WASHINGTON ST.
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-0524
Mailing Address - Country:US
Mailing Address - Phone:731-658-9522
Mailing Address - Fax:731-658-9522
Practice Address - Street 1:358 NEW BYHALIA RD
Practice Address - Street 2:SUITE 3
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-3743
Practice Address - Country:US
Practice Address - Phone:901-853-8180
Practice Address - Fax:901-853-1421
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNT875152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNT61229Medicare UPIN
TN0924860001Medicare NSC