Healthcare Provider Details

I. General information

NPI: 1447242680
Provider Name (Legal Business Name): HENRY EDWARD WOOD JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 OLIVE ST STE 200
SHREVEPORT LA
71104-2246
US

IV. Provider business mailing address

745 OLIVE ST STE 200
SHREVEPORT LA
71104-2246
US

V. Phone/Fax

Practice location:
  • Phone: 318-226-0809
  • Fax: 318-226-0812
Mailing address:
  • Phone: 318-226-0809
  • Fax: 318-226-0812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number15619
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number9905
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: