Provider Demographics
NPI:1699752113
Name:WOODWARD, MARK DENNIS (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DENNIS
Last Name:WOODWARD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 ENTERPRISE PARKWAY
Practice Address - Street 2:SUITE 1200
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-6500
Practice Address - Country:US
Practice Address - Phone:757-838-4500
Practice Address - Fax:757-896-4732
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0601001576152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA410045201Medicare PIN
VAU12528Medicare UPIN
VA00X550R08Medicare PIN
VA1699752113Medicaid