Healthcare Provider Details

I. General information

NPI: 1932283199
Provider Name (Legal Business Name): JAMES M. WOOD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 FIVE FORKS TRICKUM RD SW SUITE 112
LILBURN GA
30047-1807
US

IV. Provider business mailing address

3050 FIVE FORKS TRICKUM RD SW SUITE 112
LILBURN GA
30047-1807
US

V. Phone/Fax

Practice location:
  • Phone: 770-978-2990
  • Fax: 770-978-2993
Mailing address:
  • Phone: 770-978-2990
  • Fax: 770-978-2993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number1148-T
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: