Provider Demographics
NPI:1720125768
Name:SAMUEL T WOOD, DPM, LLC
Entity Type:Organization
Organization Name:SAMUEL T WOOD, DPM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:314-921-1020
Mailing Address - Street 1:PO BOX 771470
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63177-2470
Mailing Address - Country:US
Mailing Address - Phone:314-989-0300
Mailing Address - Fax:
Practice Address - Street 1:662 SAINT FERDINAND ST
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-5125
Practice Address - Country:US
Practice Address - Phone:314-921-1020
Practice Address - Fax:314-921-2450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000820213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO5933140002Medicare NSC
MO5933140001Medicare NSC