Provider Demographics
NPI:1356312110
Name:WOOD, MARK A (DO)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:WOOD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 N COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:OH
Mailing Address - Zip Code:44827-1455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:955 BUCYRUS RD
Practice Address - Street 2:
Practice Address - City:GALION
Practice Address - State:OH
Practice Address - Zip Code:44833
Practice Address - Country:US
Practice Address - Phone:419-468-4220
Practice Address - Fax:419-462-7019
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH345004233207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000367566OtherANTHEM BCBS
OH0645181Medicaid
OH000000367566OtherANTHEM BCBS
OH7179501Medicare ID - Type Unspecified