Provider Demographics
NPI:1285735118
Name:WOODSON, KEVIN R (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:WOODSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-5905
Mailing Address - Country:US
Mailing Address - Phone:973-429-0442
Mailing Address - Fax:973-429-8642
Practice Address - Street 1:6 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-5905
Practice Address - Country:US
Practice Address - Phone:973-429-0442
Practice Address - Fax:973-429-8642
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA04702200207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC55589Medicare UPIN