Healthcare Provider Details

I. General information

NPI: 1023145745
Provider Name (Legal Business Name): JOHN PHILIP WOODALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 BERKSHIRE RD
SANDY HOOK CT
06482
US

IV. Provider business mailing address

49 DEER HILL AVE
DANBURY CT
06810-7902
US

V. Phone/Fax

Practice location:
  • Phone: 203-491-2577
  • Fax: 203-491-2579
Mailing address:
  • Phone: 978-549-1756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number73625
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number052596
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: