Provider Demographics
NPI:1750558789
Name:THOMAS C. WOOLDIRDGE, MD: A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:THOMAS C. WOOLDIRDGE, MD: A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:CLAYTON
Authorized Official - Last Name:WOOLDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-283-0400
Mailing Address - Street 1:PO BOX 1640
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71221-1640
Mailing Address - Country:US
Mailing Address - Phone:318-283-0400
Mailing Address - Fax:318-283-0400
Practice Address - Street 1:1921 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-2431
Practice Address - Country:US
Practice Address - Phone:318-283-0400
Practice Address - Fax:318-283-0400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13859261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1303712Medicaid
LA1303712Medicaid
LA5J617Medicare PIN