Provider Demographics
NPI:1255372330
Name:WOOD, WAYNE WILLIAMSON (OD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:WILLIAMSON
Last Name:WOOD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 RIVERSIDE AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-3337
Mailing Address - Country:US
Mailing Address - Phone:904-356-7101
Mailing Address - Fax:904-356-7101
Practice Address - Street 1:806 RIVERSIDE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3337
Practice Address - Country:US
Practice Address - Phone:904-356-7101
Practice Address - Fax:904-356-7101
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1012152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20124OtherBCBS
20124AOtherBCBS
FL6183330002Medicare NSC
FLP00737871Medicare PIN
FL410040100Medicare PIN
FL20124XMedicare PIN
FL20124OtherBCBS