Provider Demographics
NPI:1982792180
Name:WOODWARD, THOMAS WHALEN (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WHALEN
Last Name:WOODWARD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 E MAIN ST
Mailing Address - Street 2:PO BOX 687
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-3034
Mailing Address - Country:US
Mailing Address - Phone:208-365-4531
Mailing Address - Fax:
Practice Address - Street 1:304 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-3034
Practice Address - Country:US
Practice Address - Phone:208-365-4531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-0557152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807303600Medicaid
ID002451000Medicaid
IDT44306Medicare UPIN
ID1590869Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE
ID807303600Medicaid
ID1368592Medicare ID - Type UnspecifiedGROUP MEDICARE