Provider Demographics
NPI:1942223920
Name:WOODWARD, KIMBALL P I
Entity Type:Individual
Prefix:DR
First Name:KIMBALL
Middle Name:P
Last Name:WOODWARD
Suffix:I
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 1:2 CROSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10994-2226
Mailing Address - Country:US
Mailing Address - Phone:845-348-3400
Mailing Address - Fax:845-348-3438
Practice Address - Street 1:2 CROSFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST NYACK
Practice Address - State:NY
Practice Address - Zip Code:10994-2226
Practice Address - Country:US
Practice Address - Phone:845-348-3400
Practice Address - Fax:845-348-3438
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1676221174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY51F171Medicare ID - Type Unspecified
NYE62364Medicare UPIN