Healthcare Provider Details

I. General information

NPI: 1467548016
Provider Name (Legal Business Name): JOHN F WOOD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 E. MAIN
CARBONDALE IL
62901
US

IV. Provider business mailing address

807 WOODLAND DR
CARTERVILLE IL
62918
US

V. Phone/Fax

Practice location:
  • Phone: 618-457-6440
  • Fax: 618-549-2232
Mailing address:
  • Phone: 618-985-2656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-008681
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT-2993
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: