Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | 038004895 | IL |
Y | 111NX0800X | Chiropractor Orthopedic Specialist | 038004895 | IL |
NPI | 1639260953 |
---|---|
Provider Name | Dr. Mark A Wood |
First Address | Raymond, IL 62560-5202 |
Second Address | Raymond, IL 62560-5202 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/09/2006 |
Last Update Date | 17/08/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
974600327 | (05) | IL |
T38032 | (02) | IL |