Healthcare Provider Details

I. General information

NPI: 1871557322
Provider Name (Legal Business Name): LARRY J. WOODS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 WILLOW DR
PLOVER WI
54467-3403
US

IV. Provider business mailing address

2801 WILLOW DR
PLOVER WI
54467-3403
US

V. Phone/Fax

Practice location:
  • Phone: 715-341-5151
  • Fax: 715-341-1016
Mailing address:
  • Phone: 715-341-5151
  • Fax: 715-341-1016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1979
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: