=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760606917
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES TATE WOODWARD DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2007
-----------------------------------------------------
Last Update Date | 11/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1745 W 33RD ST
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73013-3831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-826-2256
-----------------------------------------------------
Fax | 800-308-0241
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1745 W 33RD ST
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73013-3831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-826-2256
-----------------------------------------------------
Fax | 800-308-0241
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 18955
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------