Provider Demographics
NPI:1942343900
Name:WOODSON DERMATOLOGY
Entity Type:Organization
Organization Name:WOODSON DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNNIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WOODSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:702-367-6370
Mailing Address - Street 1:229 N PECOS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7364
Mailing Address - Country:US
Mailing Address - Phone:702-367-6370
Mailing Address - Fax:702-433-4238
Practice Address - Street 1:229 N PECOS RD STE 100
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-7364
Practice Address - Country:US
Practice Address - Phone:702-367-6370
Practice Address - Fax:702-433-4238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7014207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVVWQBBTMedicare PIN