Provider Demographics
NPI:1760820591
Name:WOODARD, COLIN MATTHEW (DO)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:MATTHEW
Last Name:WOODARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 RESERVOIR AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-6092
Mailing Address - Country:US
Mailing Address - Phone:401-943-1300
Mailing Address - Fax:
Practice Address - Street 1:1150 RESERVOIR AVE STE 201
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6092
Practice Address - Country:US
Practice Address - Phone:401-943-1300
Practice Address - Fax:401-946-8480
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDO00958207RG0100X
RILP02742390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1760820591Medicaid