Healthcare Provider Details

I. General information

NPI: 1740243013
Provider Name (Legal Business Name): GREGORY K WOOD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 LAFAYETTE
MOUNDSVILLE WV
26041-2316
US

IV. Provider business mailing address

1307 LAFAYETTE AVENUE
MOUNDSVILLE WV
26041-2316
US

V. Phone/Fax

Practice location:
  • Phone: 304-845-2500
  • Fax: 304-845-2624
Mailing address:
  • Phone: 304-845-2500
  • Fax: 304-845-2624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1248
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: