Basic Information
| Provider Information | |||||||||
| NPI: | 1740371558 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WOOD FAMILY MEDICINE, P.C. | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 409 E REDWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | SALLISAW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749553018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187753857 | ||||||||
| FaxNumber: | 9187750587 | ||||||||
| Practice Location | |||||||||
| Address1: | 409 E REDWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | SALLISAW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749553018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187753857 | ||||||||
| FaxNumber: | 9187750587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOOD | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9187753857 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 200004670A | 05 | OK | MEDICAID | 248311603 | 01 | OK | OK BC/BS GROUP NUMBER | OTHER |