Basic Information
| Provider Information | |||||||||
| NPI: | 1982690459 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOODSON | ||||||||
| FirstName: | GAYLE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 BENMORE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327924111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076444883 | ||||||||
| FaxNumber: | 4076443697 | ||||||||
| Practice Location | |||||||||
| Address1: | 133 BENMORE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327924111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076444883 | ||||||||
| FaxNumber: | 4076443697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 05/23/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 036109522 | IL | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | ME80975 | FL | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 036109522 | 05 | IL | MEDICAID |