Provider Demographics
NPI:1174528558
Name:WOODWORTH, ALFRED HERMAN (MD)
Entity type:Individual
Prefix:
First Name:ALFRED
Middle Name:HERMAN
Last Name:WOODWORTH
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 1:4402 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6161
Mailing Address - Country:US
Mailing Address - Phone:910-452-1400
Mailing Address - Fax:910-332-1072
Practice Address - Street 1:4402 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6161
Practice Address - Country:US
Practice Address - Phone:910-452-1400
Practice Address - Fax:910-332-1072
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17535207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC01-28863OtherUNITED HEALTHCARE
NC89442OtherBCBS
NCB4563OtherMEDCOST
NC930040271OtherRAILROAD MEDICARE
NC930040271OtherRAILROAD MEDICARE
NCB4563OtherMEDCOST