Healthcare Provider Details

I. General information

NPI: 1972207496
Provider Name (Legal Business Name): COLEMAN WOODY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 BOATNER RD
EGLIN AFB FL
32542-1391
US

IV. Provider business mailing address

340 BOATNER RD
EGLIN AFB FL
32542-1391
US

V. Phone/Fax

Practice location:
  • Phone: 850-883-8600
  • Fax:
Mailing address:
  • Phone: 850-883-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number84688-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: