Provider Demographics
NPI:1164621819
Name:WOOD, MICHAEL CLARK (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CLARK
Last Name:WOOD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-0307
Mailing Address - Country:US
Mailing Address - Phone:801-294-6907
Mailing Address - Fax:801-294-6917
Practice Address - Street 1:643 W 700 N
Practice Address - Street 2:SUITE C
Practice Address - City:LINDON
Practice Address - State:UT
Practice Address - Zip Code:84042-1361
Practice Address - Country:US
Practice Address - Phone:801-796-1031
Practice Address - Fax:801-796-1038
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT121944-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000061445Medicare PIN