Basic Information
| Provider Information | |||||||||
| NPI: | 1821034612 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOOD | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | GILMORE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3464 S WILLOW ST | ||||||||
| Address2: | SUITE 169 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802314531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037552900 | ||||||||
| FaxNumber: | 3037550404 | ||||||||
| Practice Location | |||||||||
| Address1: | 7720 S BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801222632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037988262 | ||||||||
| FaxNumber: | 3037988463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| 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 | 207R00000X | 23078 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | WO98101 | 01 | CO | BLUE SHIELD | OTHER | 01230788 | 05 | CO | MEDICAID |