Healthcare Provider Details

I. General information

NPI: 1750445946
Provider Name (Legal Business Name): CHARMAINE BLAKE WOODE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 SOUTH MAIN STREET
DAYTON OH
45422
US

IV. Provider business mailing address

PO BOX 750966
DAYTON OH
43475
US

V. Phone/Fax

Practice location:
  • Phone: 937-225-4954
  • Fax:
Mailing address:
  • Phone: 937-439-0676
  • Fax: 937-439-0976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35086564
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number21793
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number043150
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: