Healthcare Provider Details

I. General information

NPI: 1477576635
Provider Name (Legal Business Name): RICHARD E WOOD JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 08/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 MCCRARY RD
FORTSON GA
31808-4558
US

IV. Provider business mailing address

1315 DELAUNEY AVE SUITE 201
COLUMBUS GA
31901-2367
US

V. Phone/Fax

Practice location:
  • Phone: 706-987-8216
  • Fax: 706-987-8220
Mailing address:
  • Phone: 706-987-8216
  • Fax: 706-987-8220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19809
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: