Provider Demographics
NPI:1811083348
Name:WOODWARD, KIRK (MD)
Entity type:Individual
Prefix:
First Name:KIRK
Middle Name:
Last Name:WOODWARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:379 NORTH 500 WEST
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078
Mailing Address - Country:US
Mailing Address - Phone:435-789-1165
Mailing Address - Fax:435-789-1169
Practice Address - Street 1:379 NORTH 500 WEST
Practice Address - Street 2:SUITE 1A
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078
Practice Address - Country:US
Practice Address - Phone:435-789-1165
Practice Address - Fax:435-789-1169
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT117005-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTH34518Medicare UPIN
UT005549207Medicare ID - Type UnspecifiedMEDICARE