Healthcare Provider Details

I. General information

NPI: 1144240524
Provider Name (Legal Business Name): DENISE WOODALL-RUFF MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 WAVERLY AVE
PATCHOGUE NY
11772-1555
US

IV. Provider business mailing address

PO BOX 1559
STONY BROOK NY
11790-0989
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-6300
  • Fax:
Mailing address:
  • Phone: 631-444-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD203297
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number217208
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1808237
Identifier TypeMEDICAID
Identifier StateLA
Identifier Issuer
# 2
Identifier02204433
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: