Provider Demographics
NPI:1588670822
Name:WOOD, MATTHEW WILLIAM JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WILLIAM
Last Name:WOOD
Suffix:JR
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 1:1 MEDICAL PARK BLVD
Mailing Address - Street 2:SUITE 400 EAST
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-7430
Mailing Address - Country:US
Mailing Address - Phone:423-844-5400
Mailing Address - Fax:423-844-5434
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:SUITE 400 EAST
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-844-5400
Practice Address - Fax:423-844-5434
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000010369207T00000X
VA0101057302207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6101267Medicaid
TN3195611Medicaid
WV9801396000Medicaid
TN3195611Medicaid
TN3195613Medicare PIN
3195612Medicare ID - Type Unspecified
VAVV14679857Medicare PIN