Provider Demographics
NPI:1922294032
Name:JERRY D WOOD
Entity Type:Organization
Organization Name:JERRY D WOOD
Other - Org Name:JERRY WOOD, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-327-7147
Mailing Address - Street 1:219 NORTH EASTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351
Mailing Address - Country:US
Mailing Address - Phone:936-327-7147
Mailing Address - Fax:936-327-6234
Practice Address - Street 1:219 NORTH EASTWOOD AVE
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351
Practice Address - Country:US
Practice Address - Phone:936-327-7147
Practice Address - Fax:936-327-6234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0304174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093953001Medicaid
TX00N68XOtherBLUECROSS BLUE SHIELD
TX00N68XMedicare PIN
TXC23735Medicare UPIN