Provider Demographics
NPI:1770794604
Name:THOMAS C. WOOLDRIDGE A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:THOMAS C. WOOLDRIDGE A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:CLAYTON
Authorized Official - Last Name:WOOLDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-283-0400
Mailing Address - Street 1:1921 NORTH WASHINGTON ST.
Mailing Address - Street 2:P. O. BOX 1640
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71221-1640
Mailing Address - Country:US
Mailing Address - Phone:318-283-0400
Mailing Address - Fax:318-283-0400
Practice Address - Street 1:1921 NORTH WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71221-1640
Practice Address - Country:US
Practice Address - Phone:318-283-0400
Practice Address - Fax:318-283-0400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13859208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1303712Medicaid
LAB60545Medicare UPIN
LA1303712Medicaid