Provider Demographics
NPI:1124045638
Name:WOODARD, THERESA LYNETTE (MD)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:LYNETTE
Last Name:WOODARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 BERTRAND DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-5556
Mailing Address - Country:US
Mailing Address - Phone:337-294-1230
Mailing Address - Fax:833-749-0347
Practice Address - Street 1:539 BERTRAND DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-5556
Practice Address - Country:US
Practice Address - Phone:337-294-1230
Practice Address - Fax:833-749-0347
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN48083174400000X, 207R00000X
LA199982207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I113900OtherMEDICARE
LA1050636Medicaid
TN1527156Medicaid
TN48083OtherSTATE MEDICAL LICENSE
LA199982OtherSTATE MEDICAL LICENSE
LA199982OtherSTATE MEDICAL LICENSE