Provider Demographics
NPI:1851305486
Name:WOODWORTH, DAN
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:WOODWORTH
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 1:2700 E FOOTHILL BLVD
Mailing Address - Street 2:SUITE 121
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-7100
Mailing Address - Country:US
Mailing Address - Phone:626-449-4347
Mailing Address - Fax:626-449-4317
Practice Address - Street 1:2700 E FOOTHILL BLVD
Practice Address - Street 2:SUITE 121
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-7100
Practice Address - Country:US
Practice Address - Phone:626-449-4347
Practice Address - Fax:626-449-4317
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT19400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT19400OtherCALIFORNIA BLUE CROSS
CAZZZ03532ZOtherBLUE SHILED GROUP NUMBER
CAZZZ03532ZOtherBLUE SHILED GROUP NUMBER
CAWPT19400DMedicare ID - Type UnspecifiedWASHINGTON LOCATION