Healthcare Provider Details

I. General information

NPI: 1225032246
Provider Name (Legal Business Name): MARK R WOODSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3524 NW 56TH ST
OKLAHOMA CITY OK
73112-4518
US

IV. Provider business mailing address

3524 NW 56TH ST
OKLAHOMA CITY OK
73112-4518
US

V. Phone/Fax

Practice location:
  • Phone: 405-657-3120
  • Fax: 405-657-3122
Mailing address:
  • Phone: 405-657-3120
  • Fax: 405-657-3122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number19384
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19384
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: