Basic Information
| Provider Information | |||||||||
| NPI: | 1457378481 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOOSTER | ||||||||
| FirstName: | LYMAN | ||||||||
| MiddleName: | DWIGHT | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64264 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109550670 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 N CAROLINE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212870006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109550670 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 02/21/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | D0022043 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0002 F288 | 01 | DC | BS OF DC | OTHER | 422947-01 | 01 | MD | BS OF MD | OTHER | 409013509 | 01 | MD | RR MEDICARE | OTHER | 971491000 | 05 | MD | MEDICAID |