Provider Demographics
NPI:1750445946
Name:WOODE, CHARMAINE BLAKE (MD)
Entity Type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:BLAKE
Last Name:WOODE
Suffix:
Gender:F
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:PO BOX 750966
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:43475
Mailing Address - Country:US
Mailing Address - Phone:937-439-0676
Mailing Address - Fax:937-439-0976
Practice Address - Street 1:117 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45422
Practice Address - Country:US
Practice Address - Phone:937-225-4954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35086564208000000X
AL21793208000000X
GA043150208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2597588Medicaid