Provider Demographics
NPI:1619193869
Name:WOOD, KELLY ANN (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:WOOD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:420 COLUMBIA CTR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-2540
Mailing Address - Country:US
Mailing Address - Phone:618-719-2011
Mailing Address - Fax:618-417-6046
Practice Address - Street 1:420 COLUMBIA CTR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-2540
Practice Address - Country:US
Practice Address - Phone:618-791-2011
Practice Address - Fax:618-417-6046
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146940207Q00000X
IL89988457207QB0002X
IL036123456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine