Provider Demographics
NPI:1548359045
Name:WOOD, JEFFERY B
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:B
Last Name:WOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 N ALLEN DR
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-2539
Mailing Address - Country:US
Mailing Address - Phone:972-727-5717
Mailing Address - Fax:972-727-9927
Practice Address - Street 1:321 N ALLEN DR
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-2539
Practice Address - Country:US
Practice Address - Phone:972-727-5717
Practice Address - Fax:972-727-9927
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3241TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093398803Medicaid
TXTXB152282Medicare PIN
T16728Medicare UPIN
TX093398803Medicaid