Provider Demographics
NPI:1275648677
Name:WOOD, BRYAN WESLEY (OD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:WESLEY
Last Name:WOOD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3019 WILLIAM STREET
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703
Mailing Address - Country:US
Mailing Address - Phone:573-339-2020
Mailing Address - Fax:844-380-2020
Practice Address - Street 1:3019 WILLIAM STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703
Practice Address - Country:US
Practice Address - Phone:573-339-2020
Practice Address - Fax:844-380-2020
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY2195DT152W00000X
IL046.009893152W00000X
MO2006017344152WC0802X
MO2006 17344152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management