Healthcare Provider Details

I. General information

NPI: 1053481531
Provider Name (Legal Business Name): MATTHEW J. WOOD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 12TH AVE RD
NAMPA ID
83686-6008
US

IV. Provider business mailing address

1512 12TH AVE RD
NAMPA ID
83686-6008
US

V. Phone/Fax

Practice location:
  • Phone: 208-463-5029
  • Fax:
Mailing address:
  • Phone: 208-463-5029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberM-6494
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number328720-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: