=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801175161
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOODWARD FAMILY MEDICINE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2011
-----------------------------------------------------
Last Update Date | 02/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1024 MAIN ST
-----------------------------------------------------
City | WOODWARD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73801-3120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-254-5353
-----------------------------------------------------
Fax | 580-254-5354
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1024 MAIN ST
-----------------------------------------------------
City | WOODWARD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73801-3120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-254-5353
-----------------------------------------------------
Fax | 580-254-5354
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. WALTER R KLASSEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 580-254-5353
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 23902
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------