MEDICARE: DR. GWENDOLYN A. WOODEN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	0618001194	VA

General Provider Information

NPI Number	:	1962440156
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GWENDOLYN A. WOODEN O.D.

Provider Business Mailing Address
First Line	:	1800 LAUREL SPRINGS RD
Second Line	:
City	:	SPRING GROVE
State	:	VA
Zip	:	23881-8602
Country	:	US
Telephone Number	:	301-908-6538
Fax Number	:	804-526-5289

Provider Business Practice Location Address
First Line	:	1847B SOUTHPARK BLVD
Second Line	:
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-3607
Country	:	US
Telephone Number	:	804-526-7830
Fax Number	:	804-526-5289

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	07/08/2007

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