Healthcare Provider Details

I. General information

NPI: 1699055236
Provider Name (Legal Business Name): JONATHAN STEPHEN WOOD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2011
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 FIVE FORKS TRICKUM RD SW STE 102
LILBURN GA
30047-8975
US

IV. Provider business mailing address

4120 FIVE FORKS TRICKUM RD SW STE 102
LILBURN GA
30047-8975
US

V. Phone/Fax

Practice location:
  • Phone: 770-923-6400
  • Fax: 770-676-9876
Mailing address:
  • Phone: 770-923-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number76998
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: