Provider Demographics
NPI:1205914181
Name:WOODARD, BRIAN E (DC)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:E
Last Name:WOODARD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1477
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903-1477
Mailing Address - Country:US
Mailing Address - Phone:618-529-4545
Mailing Address - Fax:618-529-2822
Practice Address - Street 1:100 N GLENVIEW DR
Practice Address - Street 2:SUITE 101
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-2275
Practice Address - Country:US
Practice Address - Phone:618-529-4545
Practice Address - Fax:618-529-2822
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0380003887111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK32941Medicare PIN
ILT37876Medicare UPIN