Provider Demographics
NPI:1295806487
Name:WOO, WHA-JA (MD)
Entity type:Individual
Prefix:
First Name:WHA-JA
Middle Name:
Last Name:WOO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:WHA-JA
Other - Middle Name:W
Other - Last Name:FENTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:632 BLUE HILL AVENUE
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02121
Mailing Address - Country:US
Mailing Address - Phone:617-825-3400
Mailing Address - Fax:617-282-1450
Practice Address - Street 1:632 BLUE HILL AVENUE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02121
Practice Address - Country:US
Practice Address - Phone:617-825-3400
Practice Address - Fax:617-282-1450
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-11
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA38812208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1301896Medicaid
MAM09638Medicare ID - Type Unspecified
MAE03286Medicare UPIN