Provider Demographics
NPI:1760621791
Name:WOODHAM, MATTHEW LEO (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:LEO
Last Name:WOODHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-1257
Mailing Address - Country:US
Mailing Address - Phone:641-628-3150
Mailing Address - Fax:641-628-8901
Practice Address - Street 1:404 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-1257
Practice Address - Country:US
Practice Address - Phone:641-628-3150
Practice Address - Fax:641-628-8901
Is Sole Proprietor?:No
Enumeration Date:2009-02-15
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11367207R00000X
IA4473207R00000X
IADO-04473207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1760621791OtherNPI NUMBER
IADO04473OtherIOWA LICENSE
1760621791OtherNPI NUMBER