Provider Demographics
NPI:1932238169
Name:WOODARD, JERRY C (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:C
Last Name:WOODARD
Suffix:
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:PO BOX 7014
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27895-7014
Mailing Address - Country:US
Mailing Address - Phone:252-243-7977
Mailing Address - Fax:252-399-0514
Practice Address - Street 1:2605 FOREST HILLS RD SW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4448
Practice Address - Country:US
Practice Address - Phone:252-243-7977
Practice Address - Fax:252-399-0514
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16053174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0225GOtherBLUE CROSS BLUE SHIELD
NC8989085Medicaid
NC0225GOtherBLUE CROSS BLUE SHIELD
NCC87271Medicare UPIN