Healthcare Provider Details

I. General information

NPI: 1578551370
Provider Name (Legal Business Name): WILLIAM WYATT WOOD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1495 NORTHROCK CT
ROCKFORD IL
61103-1233
US

IV. Provider business mailing address

1495 NORTHROCK CT
ROCKFORD IL
61103-1233
US

V. Phone/Fax

Practice location:
  • Phone: 815-885-1462
  • Fax: 815-885-2895
Mailing address:
  • Phone: 815-965-1817
  • Fax: 815-965-9574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036-076277
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: