Healthcare Provider Details

I. General information

NPI: 1558358994
Provider Name (Legal Business Name): RYAN T WOOD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3655 W ANTHEM WAY SUITE 109 PMB 313
ANTHEM AZ
85086-0430
US

IV. Provider business mailing address

3655 W ANTHEM WAY SUITE A109 PMB 313
ANTHEM AZ
85086-0430
US

V. Phone/Fax

Practice location:
  • Phone: 623-505-9880
  • Fax: 623-505-9880
Mailing address:
  • Phone: 623-505-9880
  • Fax: 623-505-9880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number4263
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4263
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: