Provider Demographics
NPI:1922000918
Name:WOFFORD, PERISCO A (MD)
Entity Type:Individual
Prefix:DR
First Name:PERISCO
Middle Name:A
Last Name:WOFFORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4567 MILLBRANCH RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-7437
Mailing Address - Country:US
Mailing Address - Phone:901-034-5145
Mailing Address - Fax:901-345-1456
Practice Address - Street 1:4567 MILLBRANCH RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-7437
Practice Address - Country:US
Practice Address - Phone:901-345-1454
Practice Address - Fax:901-345-1456
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37436207P00000X
TNMD0000037436207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3886982Medicaid
TN3886982Medicaid
TN3378650Medicare ID - Type UnspecifiedGRP
TNH88210Medicare UPIN
TN3886982Medicaid