Healthcare Provider Details

I. General information

NPI: 1346619558
Provider Name (Legal Business Name): MATTHEW SHAUN WOODRUFF IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2015
Last Update Date: 09/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

POST OFFICE BOX 66038 MARINE AIRCRAFT GROUP 31
BEAUFORT SC
29904-6038
US

IV. Provider business mailing address

43 WHITE POND BLVD
BEAUFORT SC
29902-3338
US

V. Phone/Fax

Practice location:
  • Phone: 843-228-6257
  • Fax:
Mailing address:
  • Phone: 210-551-3162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: