Provider Demographics
NPI:1629695929
Name:WOODWORTH, JOHN RANDALL
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RANDALL
Last Name:WOODWORTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 S CREASY LN STE 100B
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-5206
Mailing Address - Country:US
Mailing Address - Phone:765-420-5800
Mailing Address - Fax:765-423-6099
Practice Address - Street 1:421 EAST 300 SOUTH
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:IN
Practice Address - Zip Code:47971
Practice Address - Country:US
Practice Address - Phone:765-884-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36003657A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer