Basic Information
| Provider Information | |||||||||
| NPI: | 1912973330 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOODWARD | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100517 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761850517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177317771 | ||||||||
| FaxNumber: | 8177317774 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S BURMA AVE | ||||||||
| Address2: | |||||||||
| City: | GILLETTE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 827163426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076881244 | ||||||||
| FaxNumber: | 3076881224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2006 | ||||||||
| LastUpdateDate: | 05/01/2008 | ||||||||
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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 | 207ZP0101X | 5471A | WY | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZC0006X | 5471A | WY | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 307127 | 01 | WY | BCBS | OTHER | 220032568 | 01 | WY | MEDICARE RR | OTHER | 122244900 | 05 | WY | MEDICAID |