Provider Demographics
NPI:1780216622
Name:WOODS, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WOODS
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 1:802 MOUNTAINEER LN APT C
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-4132
Mailing Address - Country:US
Mailing Address - Phone:618-841-8723
Mailing Address - Fax:
Practice Address - Street 1:802 MOUNTAINEER LN APT C
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-4132
Practice Address - Country:US
Practice Address - Phone:618-841-8723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-09
Last Update Date:2020-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILW320-1676-0107172A00000X
172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver