Provider Demographics
NPI:1659700268
Name:WOOD, OMAR
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:WOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 ANDERSON RD
Mailing Address - Street 2:UNIT 81
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-6002
Mailing Address - Country:US
Mailing Address - Phone:615-557-0204
Mailing Address - Fax:
Practice Address - Street 1:3401 ANDERSON RD
Practice Address - Street 2:UNIT 81
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-6002
Practice Address - Country:US
Practice Address - Phone:615-557-0204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN01-291174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist