Provider Demographics
NPI:1700877388
Name:WOODARD, GERALD R (DO)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:R
Last Name:WOODARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3512 S ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:32118-7639
Mailing Address - Country:US
Mailing Address - Phone:386-767-9544
Mailing Address - Fax:386-756-0501
Practice Address - Street 1:3512 S ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH SHORES
Practice Address - State:FL
Practice Address - Zip Code:32118-7639
Practice Address - Country:US
Practice Address - Phone:386-767-9544
Practice Address - Fax:386-756-0501
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4717207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD60686Medicare UPIN