Provider Demographics
NPI:1356513568
Name:WILLIAM R WOODMAN OD PC
Entity type:Organization
Organization Name:WILLIAM R WOODMAN OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:WOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-549-2851
Mailing Address - Street 1:PO BOX 1329
Mailing Address - Street 2:
Mailing Address - City:SISTERS
Mailing Address - State:OR
Mailing Address - Zip Code:97759-1329
Mailing Address - Country:US
Mailing Address - Phone:541-549-2851
Mailing Address - Fax:541-549-4473
Practice Address - Street 1:492 E MAIN AVE
Practice Address - Street 2:
Practice Address - City:SISTERS
Practice Address - State:OR
Practice Address - Zip Code:97759-1329
Practice Address - Country:US
Practice Address - Phone:541-549-2851
Practice Address - Fax:541-549-4473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2164ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR061085Medicaid
OR4390720002Medicare NSC
ORR112500Medicare PIN
OR061085Medicaid