Provider Demographics
NPI:1639252166
Name:WOODALL, CHARLES E JR (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
Last Name:WOODALL
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:18598 HIGHWAY 13 NORTH
Practice Address - Street 2:
Practice Address - City:BRANSON WEST
Practice Address - State:MO
Practice Address - Zip Code:65616
Practice Address - Country:US
Practice Address - Phone:417-272-8497
Practice Address - Fax:417-272-8496
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2008-07-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MOR2D64207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO241848100Medicaid
MOA10385Medicare UPIN
MO016013230Medicare PIN
MO241848100Medicaid