Provider Demographics
NPI:1881882215
Name:DR. C. MICHAEL WOOD
Entity type:Organization
Organization Name:DR. C. MICHAEL WOOD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:812-649-4266
Mailing Address - Street 1:102 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:IN
Mailing Address - Zip Code:47635-1460
Mailing Address - Country:US
Mailing Address - Phone:812-649-4266
Mailing Address - Fax:812-649-4279
Practice Address - Street 1:102 N 6TH ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:IN
Practice Address - Zip Code:47635-1460
Practice Address - Country:US
Practice Address - Phone:812-649-4266
Practice Address - Fax:812-649-4279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001549A332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100224880AMedicaid
0992470001Medicare NSC
U28151Medicare UPIN