Provider Demographics
NPI:1942485354
Name:WOODWORTH, GREG (OD)
Entity Type:Individual
Prefix:DR
First Name:GREG
Middle Name:
Last Name:WOODWORTH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 FLETCHER PKWY
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-2522
Mailing Address - Country:US
Mailing Address - Phone:619-447-5555
Mailing Address - Fax:619-447-5089
Practice Address - Street 1:575 FLETCHER PKWY
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-2522
Practice Address - Country:US
Practice Address - Phone:619-447-5555
Practice Address - Fax:619-447-5089
Is Sole Proprietor?:No
Enumeration Date:2008-01-03
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7606TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0076060Medicaid
CA16377OtherMEDICAL EYE SERVICES
CA46555OtherSAFEGUARD HMO
CA50301OtherSAFEGUARD PPO
CAT95657Medicare UPIN
CASD0076060Medicaid
CA50301OtherSAFEGUARD PPO