Provider Demographics
NPI:1316482094
Name:WOODCOCK, JR, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WOODCOCK, JR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 SALEM TPKE
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-6455
Mailing Address - Country:US
Mailing Address - Phone:860-887-6696
Mailing Address - Fax:860-887-7850
Practice Address - Street 1:220 SALEM TPKE
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-6455
Practice Address - Country:US
Practice Address - Phone:860-887-6696
Practice Address - Fax:860-887-7850
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000724156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician