Healthcare Provider Details

I. General information

NPI: 1700894664
Provider Name (Legal Business Name): JESSE W ATWOOD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 S WOODWORTH LOOP
PALMER AK
99645-8984
US

IV. Provider business mailing address

PO BOX 876166
WASILLA AK
99687-6166
US

V. Phone/Fax

Practice location:
  • Phone: 907-861-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number7328
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier8355976
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 2
IdentifierMD4770
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: