Provider Demographics
NPI:1639260953
Name:WOOD, MARK A (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:WOOD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:IL
Mailing Address - Zip Code:62560-5202
Mailing Address - Country:US
Mailing Address - Phone:217-573-2400
Mailing Address - Fax:
Practice Address - Street 1:506 E BROAD ST
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:IL
Practice Address - Zip Code:62560-5202
Practice Address - Country:US
Practice Address - Phone:217-573-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038004895111NX0800X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL974600327Medicaid
ILT38032Medicare UPIN
IL349860Medicare ID - Type Unspecified
IL974600327Medicaid