Provider Demographics
NPI:1689317570
Name:WOODWARD, ZACHARY
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:WOODWARD
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 1:1400 FLORIDA AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4446
Mailing Address - Country:US
Mailing Address - Phone:209-558-4000
Mailing Address - Fax:209-558-5036
Practice Address - Street 1:401 PARADISE RD STE E
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95351-3163
Practice Address - Country:US
Practice Address - Phone:209-558-4000
Practice Address - Fax:209-558-5036
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
CA2610390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer