Provider Demographics
NPI:1255328969
Name:WOOD, GORDON STACEY (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:STACEY
Last Name:WOOD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2380 N 400 E
Mailing Address - Street 2:SUITE #D
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1749
Mailing Address - Country:US
Mailing Address - Phone:435-753-7880
Mailing Address - Fax:435-753-5845
Practice Address - Street 1:1219 N 400 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2321
Practice Address - Country:US
Practice Address - Phone:435-565-6043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT185282-1205207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTF02042Medicare UPIN