Provider Demographics
NPI:1124110994
Name:WOODYEAR,JR, JOHN MONTGOMERY (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MONTGOMERY
Last Name:WOODYEAR,JR
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 1:507 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NC
Mailing Address - Zip Code:27371-2709
Mailing Address - Country:US
Mailing Address - Phone:910-576-0042
Mailing Address - Fax:910-576-1442
Practice Address - Street 1:507 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NC
Practice Address - Zip Code:27371-2709
Practice Address - Country:US
Practice Address - Phone:910-576-0042
Practice Address - Fax:910-576-1442
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500278207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQPA139OtherMEDICAID
NC8988912Medicaid
NC8988912Medicaid