Provider Demographics
NPI:1912090762
Name:STEPHEN W WOODSON DO INC
Entity Type:Organization
Organization Name:STEPHEN W WOODSON DO INC
Other - Org Name:WOODSON FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:W
Authorized Official - Last Name:WOODSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-967-3355
Mailing Address - Street 1:PO BOX 480
Mailing Address - Street 2:
Mailing Address - City:STIGLER
Mailing Address - State:OK
Mailing Address - Zip Code:74462-0480
Mailing Address - Country:US
Mailing Address - Phone:918-967-3355
Mailing Address - Fax:918-967-8863
Practice Address - Street 1:907 NW 5TH ST
Practice Address - Street 2:
Practice Address - City:STIGLER
Practice Address - State:OK
Practice Address - Zip Code:74462-1611
Practice Address - Country:US
Practice Address - Phone:918-967-3355
Practice Address - Fax:918-967-8863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2123207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
080020414OtherRR MEDICARE
OK100089460AMedicaid
OK900522548Medicare PIN
OK100089460AMedicaid