Healthcare Provider Details

I. General information

NPI: 1427251776
Provider Name (Legal Business Name): LAVON JENEEN WOOD M. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 03/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 SKYLINE DR
RUSSELLVILLE AR
72801-3362
US

IV. Provider business mailing address

108 SKYLINE DR
RUSSELLVILLE AR
72801-3362
US

V. Phone/Fax

Practice location:
  • Phone: 479-968-7170
  • Fax: 479-890-2467
Mailing address:
  • Phone: 479-968-7170
  • Fax: 479-890-2467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-6054
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: