Provider Demographics
NPI:1669460283
Name:WOODHOUSE, WALTER R (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:R
Last Name:WOODHOUSE
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 1:9050 LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPERANCE
Mailing Address - State:MI
Mailing Address - Zip Code:48182-1608
Mailing Address - Country:US
Mailing Address - Phone:734-850-8902
Mailing Address - Fax:734-850-8934
Practice Address - Street 1:9050 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TEMPERANCE
Practice Address - State:MI
Practice Address - Zip Code:48182-1608
Practice Address - Country:US
Practice Address - Phone:734-850-8902
Practice Address - Fax:734-850-8934
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-07
Last Update Date:2016-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIWW045624207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B46143Medicare UPIN
MI4014561Medicare ID - Type Unspecified