Basic Information
| Provider Information | |||||||||
| NPI: | 1124045638 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOODARD | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | LYNETTE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 539 BERTRAND DR | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705065556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372941230 | ||||||||
| FaxNumber: | 8337490347 | ||||||||
| Practice Location | |||||||||
| Address1: | 539 BERTRAND DR | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705065556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372941230 | ||||||||
| FaxNumber: | 8337490347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 12/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 48083 | TN | N | Other Service Providers | Specialist | 207R00000X | 48083 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 199982 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 103I113900 | 01 | TN | MEDICARE | OTHER | BW9458692 | 01 | DEA | OTHER | 1050636 | 05 | LA | MEDICAID | 1527156 | 05 | TN | MEDICAID | 48083 | 01 | TN | STATE MEDICAL LICENSE | OTHER | 199982 | 01 | LA | STATE MEDICAL LICENSE | OTHER |