Provider Demographics
NPI:1649203688
Name:WOODY, WALTER W (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:W
Last Name:WOODY
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 1:8060 WOLF RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1727
Mailing Address - Country:US
Mailing Address - Phone:901-271-1000
Mailing Address - Fax:901-271-4187
Practice Address - Street 1:100 BAPTIST MEMORIAL CIR STE 201
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-4476
Practice Address - Country:US
Practice Address - Phone:901-271-1000
Practice Address - Fax:901-271-4187
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11097207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114996Medicaid
MS060000804Medicare ID - Type Unspecified
MS00114996Medicaid
MS512I060004Medicare PIN
MS302I060073Medicare PIN