Basic Information
| Provider Information | |||||||||
| NPI: | 1649566076 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOODALL | ||||||||
| FirstName: | JIMMIE | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE # MC845 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1005 W GREEN ST | ||||||||
| Address2: | STE 301 | ||||||||
| City: | HASTINGS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490581712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699458080 | ||||||||
| FaxNumber: | 2699458081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2011 | ||||||||
| LastUpdateDate: | 02/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 5101019223 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.