Provider Demographics
NPI:1245305713
Name:WOMACK, BEVERLY FORTNER (MD)
Entity type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:FORTNER
Last Name:WOMACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:BEVERLY
Other - Middle Name:FORTNER
Other - Last Name:WOMACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:381 DEERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5009
Mailing Address - Country:US
Mailing Address - Phone:828-268-8970
Mailing Address - Fax:828-262-1587
Practice Address - Street 1:381 DEERFIELD RD
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5009
Practice Address - Country:US
Practice Address - Phone:828-268-8970
Practice Address - Fax:828-262-1587
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046915207V00000X
NC2008-01844207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00910225AMedicaid
GAH53351Medicare UPIN
GA16BDTWHMedicare ID - Type Unspecified