Provider Demographics
NPI:1982687125
Name:WODICKA, DAVID M (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:WODICKA
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 1:2019 TATE SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1111
Mailing Address - Country:US
Mailing Address - Phone:434-846-7374
Mailing Address - Fax:434-846-1910
Practice Address - Street 1:2019 TATE SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1111
Practice Address - Country:US
Practice Address - Phone:434-846-7374
Practice Address - Fax:434-846-1910
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036506207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080027740OtherMEDICARE RAILROAD PROVIDER NUMBER
065993OtherANTHEM
VA005601622Medicaid
080027740OtherMEDICARE RAILROAD PROVIDER NUMBER
VA005601622Medicaid