Basic Information
Provider Information | |||||||||
NPI: | 1295781409 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WARD | ||||||||
FirstName: | VIRGINIA | ||||||||
MiddleName: | WOOTEN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7901 EMERALD DR | ||||||||
Address2: |   | ||||||||
City: | EMERALD ISLE | ||||||||
State: | NC | ||||||||
PostalCode: | 285942846 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2523546500 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7901 EMERALD DR | ||||||||
Address2: |   | ||||||||
City: | EMERALD ISLE | ||||||||
State: | NC | ||||||||
PostalCode: | 285942846 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2523546500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/26/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 9600211 | NC | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 12013 | 01 | NC | BCBS OF NC | OTHER | 8912013 | 05 | NC |   | MEDICAID |