Provider Demographics
NPI:1780727750
Name:WOODSON, JOHNNIE M JR (MD)
Entity type:Individual
Prefix:DR
First Name:JOHNNIE
Middle Name:M
Last Name:WOODSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 TOWNE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5900
Mailing Address - Country:US
Mailing Address - Phone:909-398-1550
Mailing Address - Fax:909-398-1573
Practice Address - Street 1:9190 HAVEN AVE STE 210
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5431
Practice Address - Country:US
Practice Address - Phone:909-466-7779
Practice Address - Fax:909-466-9680
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51198207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVF81457Medicare UPIN
NVWQBBT01Medicare ID - Type Unspecified