Provider Demographics
NPI:1952788747
Name:WOODALL, MICHAEL THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:WOODALL
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 1:777 PARK AVE W
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2433
Mailing Address - Country:US
Mailing Address - Phone:847-926-5840
Mailing Address - Fax:847-926-5835
Practice Address - Street 1:777 PARK AVE W
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2433
Practice Address - Country:US
Practice Address - Phone:847-926-5840
Practice Address - Fax:847-926-5835
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-30
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301107864208000000X
390200000X
IL036155855208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program