Healthcare Provider Details

I. General information

NPI: 1134155971
Provider Name (Legal Business Name): BONNIE N. WOODALL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 08/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-2195
  • Fax: 601-815-1050
Mailing address:
  • Phone: 601-984-2195
  • Fax: 601-815-1050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number11066
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: