Basic Information
| Provider Information | |||||||||
| NPI: | 1427251776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOOD | ||||||||
| FirstName: | LAVON | ||||||||
| MiddleName: | JENEEN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728013362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799687170 | ||||||||
| FaxNumber: | 4798902467 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728013362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799687170 | ||||||||
| FaxNumber: | 4798902467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 03/10/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E-6054 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 183739001 | 05 | AR | MEDICAID |