Provider Demographics
NPI:1740243013
Name:WOOD, GREGORY K (DO)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:K
Last Name:WOOD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 LAFAYETTE AVENUE
Mailing Address - Street 2:
Mailing Address - City:MOUNDSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26041-2316
Mailing Address - Country:US
Mailing Address - Phone:304-845-2500
Mailing Address - Fax:304-845-2624
Practice Address - Street 1:1307 LAFAYETTE
Practice Address - Street 2:
Practice Address - City:MOUNDSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26041-2316
Practice Address - Country:US
Practice Address - Phone:304-845-2500
Practice Address - Fax:304-845-2624
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1248207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0042806000Medicaid
OH0805945Medicaid
000617588OtherBC
WO0674382Medicare ID - Type Unspecified