Basic Information
| Provider Information | |||||||||
| NPI: | 1649614082 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOODS | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 370 | ||||||||
| Address2: | |||||||||
| City: | FORTSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 318080370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 7064943008 | ||||||||
| Practice Location | |||||||||
| Address1: | 4689 US HIGHWAY 17 STE 12 | ||||||||
| Address2: | |||||||||
| City: | FLEMING ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320034831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0437597539 | ||||||||
| FaxNumber: | 9043758380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2013 | ||||||||
| LastUpdateDate: | 05/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | ME141406 | FL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0801X | ME141406 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma |
ID Information
| ID | Type | State | Issuer | Description | XEI0G | 01 | FL | FL BLUE | OTHER | 103539300 | 05 | FL | MEDICAID | LK096 | 01 | FL | MEDICARE | OTHER |