Basic Information
| Provider Information | |||||||||
| NPI: | 1639252166 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOODALL | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2580 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658012580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294620 | ||||||||
| FaxNumber: | 4178294316 | ||||||||
| Practice Location | |||||||||
| Address1: | 18598 HIGHWAY 13 NORTH | ||||||||
| Address2: | |||||||||
| City: | BRANSON WEST | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172728497 | ||||||||
| FaxNumber: | 4172728496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 07/17/2008 | ||||||||
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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 | 207Q00000X | R2D64 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 241848100 | 05 | MO | MEDICAID |