Provider Demographics
NPI:1659350650
Name:WOOD, BRYAN T (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:T
Last Name:WOOD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 E MAIN ST
Mailing Address - Street 2:PO BOX 8674
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5066
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:
Practice Address - Street 1:1230 E MAIN ST
Practice Address - Street 2:MANKATO CLINIC @ MAIN STREET
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5066
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43467208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1700938OtherMEDICA MN
HP38121OtherHEALTH PARTNERS MN
020054167OtherRR MEDICARE
171077OtherUCARE MN
2149398OtherAMERICAS PPO MN
IA0593053Medicaid
410849339 56001 C198OtherCHAMPUS
NA2951034555OtherPREFERRED ONE MN
027L5WOOtherBCBS MN
MN988153100Medicaid
HP38121OtherHEALTH PARTNERS MN
020054167OtherRR MEDICARE