Provider Demographics
NPI:1740383348
Name:DEIRDRE WOOD MD PC
Entity Type:Organization
Organization Name:DEIRDRE WOOD MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEIRDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:267-731-1333
Mailing Address - Street 1:8001 ROOSEVELT BOULEVARD
Mailing Address - Street 2:SMYLIE TIMES BLDG; SUITE 307
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-3039
Mailing Address - Country:US
Mailing Address - Phone:267-731-1333
Mailing Address - Fax:267-731-1284
Practice Address - Street 1:8001 ROOSEVELT BOULEVARD
Practice Address - Street 2:SMYLIE TIMES BLDG; SUITE 307
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-3039
Practice Address - Country:US
Practice Address - Phone:267-731-1333
Practice Address - Fax:267-731-1284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207N00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7018518OtherAETNA
PA073707Medicare PIN
3325878OtherAETNA