1538270962 NPI number — MR. CARLAS DEWAYNE WOODEN LPTA

Table of content: MR. CARLAS DEWAYNE WOODEN LPTA (NPI 1538270962)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538270962 NPI number — MR. CARLAS DEWAYNE WOODEN LPTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOODEN
Provider First Name:
CARLAS
Provider Middle Name:
DEWAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LPTA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538270962
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 SHADOW POND
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBLIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31021-6416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-296-1733
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1826 VETERANS BLVD
Provider Second Line Business Practice Location Address:
G&EC SERVICE LINE BLDG 11A
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31021-3620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-272-1210
Provider Business Practice Location Address Fax Number:
478-274-5514
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225200000X , with the licence number:  PTA002043 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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