Basic Information
| Provider Information | |||||||||
| NPI: | 1699055236 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOOD | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | STEPHEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705357445 | ||||||||
| Practice Location | |||||||||
| Address1: | 4019 EXECUTIVE DRIVE | ||||||||
| Address2: | |||||||||
| City: | OAKWOOD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305663433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705336500 | ||||||||
| FaxNumber: | 7705336543 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2011 | ||||||||
| LastUpdateDate: | 07/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 76998 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 06047829 | 01 | GA | AMERIGROUP | OTHER | 003172167L | 05 | GA | MEDICAID | 003172167K | 05 | GA | MEDICAID | 003172167J | 05 | GA | MEDICAID | 003172167M | 05 | GA | MEDICAID | 76998 | 01 | GA | GEORGIA MEDICAL LICENSE | OTHER | 003172167N | 05 | GA | MEDICAID | 003172167H | 05 | GA | MEDICAID | 003172167I | 05 | GA | MEDICAID | 1707074 | 01 | GA | WELLCARE | OTHER |