Provider Demographics
NPI:1700858255
Name:WOOD, JACOB MYLES (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:MYLES
Last Name:WOOD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8595 PICARDY AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3674
Mailing Address - Country:US
Mailing Address - Phone:225-763-4900
Mailing Address - Fax:225-763-4066
Practice Address - Street 1:8595 PICARDY AVE STE 100
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3674
Practice Address - Country:US
Practice Address - Phone:225-763-4900
Practice Address - Fax:225-763-4066
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL00024312207Q00000X
LA202160207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00141370OtherRAIL ROAD MEDICARE
AL051522945Medicaid
ALH51432OtherVIVA HEALTH
LA1328201Medicaid
LA1347957Medicaid
ALH51432OtherHEALTHSPRING OF AL
LA1319368Medicaid
AL51522945OtherBLUE CROSS BLUE SHIELD
LA1328201Medicaid
LA1347957Medicaid
LA4N2877DF59Medicare PIN
LA4N2877387Medicare PIN