Basic Information
| Provider Information | |||||||||
| NPI: | 1730279506 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOODALL | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 E PRIMROSE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178753000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1001 E PRIMROSE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178753000 | ||||||||
| FaxNumber: | 4178753245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 12/27/2018 | ||||||||
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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 | 208600000X | 2002024530 | MO | N | Allopathic & Osteopathic Physicians | Surgery | 2086X0206X | 2002024530 | MO | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1730279506 | 05 | MO | MEDICAID | 209419902 | 05 | MO | MEDICAID |