Provider Demographics
NPI:1760425250
Name:UNDERWOOD, DAVID W (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2273 N HIGHLAND AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-4909
Mailing Address - Country:US
Mailing Address - Phone:731-664-9977
Mailing Address - Fax:731-664-9484
Practice Address - Street 1:2273 N HIGHLAND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-4909
Practice Address - Country:US
Practice Address - Phone:731-664-9977
Practice Address - Fax:731-664-9484
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000019471207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3044467Medicaid
6959071OtherCIGNA
4077483OtherBCBS
D17149Medicare UPIN
TN3044467Medicare ID - Type Unspecified