Basic Information
| Provider Information | |||||||||
| NPI: | 1447242680 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOOD | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 745 OLIVE ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711042246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182260809 | ||||||||
| FaxNumber: | 3182260812 | ||||||||
| Practice Location | |||||||||
| Address1: | 745 OLIVE ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711042246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182260809 | ||||||||
| FaxNumber: | 3182260812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 15619 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | 9905 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 1949442 | 05 | LA | MEDICAID |