1114309986 NPI number — MRS. SUSAN EARNESTINE WOFFORD D.M.D

Table of content: MRS. SUSAN EARNESTINE WOFFORD D.M.D (NPI 1114309986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114309986 NPI number — MRS. SUSAN EARNESTINE WOFFORD D.M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOFFORD
Provider First Name:
SUSAN
Provider Middle Name:
EARNESTINE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
D.M.D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HIMSCHOOT
Provider Other First Name:
SUSAN
Provider Other Middle Name:
WOFFORD
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.M.D
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114309986
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2241 STATE STREET
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
NEW ALBANY
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-945-5100
Provider Business Mailing Address Fax Number:
502-459-4226

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 BENJAMIN LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40222-5813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-423-7868
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/29/2015

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: 122300000X , with the licence number:  9716 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 122300000X , with the licence number: 12013505A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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