Provider Demographics
NPI:1437209087
Name:WOOD, WAYNE R (OD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:R
Last Name:WOOD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 99TH ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210-1239
Mailing Address - Country:US
Mailing Address - Phone:941-749-8384
Mailing Address - Fax:941-729-3736
Practice Address - Street 1:319 7TH ST W
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:FL
Practice Address - Zip Code:34221-5206
Practice Address - Country:US
Practice Address - Phone:941-729-5516
Practice Address - Fax:941-729-3736
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 2420152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078975500Medicaid
FL078986100Medicaid
FL650307391OtherTIN
FL650307391OtherTIN
FL0852210001Medicare NSC
FL20103ZMedicare PIN