Healthcare Provider Details

I. General information

NPI: 1760742084
Provider Name (Legal Business Name): DAVID WILLIAM WOOD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2360 KATY LN
POPLAR BLUFF MO
63901-2300
US

IV. Provider business mailing address

2360 KATY LN
POPLAR BLUFF MO
63901-2300
US

V. Phone/Fax

Practice location:
  • Phone: 573-712-2546
  • Fax: 573-712-2549
Mailing address:
  • Phone: 573-712-2546
  • Fax: 573-712-2549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberSL0879
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2015008277
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: