Healthcare Provider Details

I. General information

NPI: 1255328969
Provider Name (Legal Business Name): GORDON STACEY WOOD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 N 400 E
LOGAN UT
84341-2321
US

IV. Provider business mailing address

2380 N 400 E SUITE #D
NORTH LOGAN UT
84341-1749
US

V. Phone/Fax

Practice location:
  • Phone: 435-565-6043
  • Fax:
Mailing address:
  • Phone: 435-753-7880
  • Fax: 435-753-5845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number185282-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: