Healthcare Provider Details

I. General information

NPI: 1124399423
Provider Name (Legal Business Name): DEMETRIUS LEON WOODS II M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2012
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 CHURCH ST NE
MARIETTA GA
30060
US

IV. Provider business mailing address

805 SANDY PLAINS ROAD MEDICAL STAFF SERVICES
MARIETTA GA
30066-6340
US

V. Phone/Fax

Practice location:
  • Phone: 770-732-4025
  • Fax: 770-732-4023
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number67840
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number67840
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number67840
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number67840
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: