Basic Information
| Provider Information | |||||||||
| NPI: | 1740383348 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEIRDRE WOOD MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8001 ROOSEVELT BOULEVARD | ||||||||
| Address2: | SMYLIE TIMES BLDG; SUITE 307 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191523039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2677311333 | ||||||||
| FaxNumber: | 2677311284 | ||||||||
| Practice Location | |||||||||
| Address1: | 8001 ROOSEVELT BOULEVARD | ||||||||
| Address2: | SMYLIE TIMES BLDG; SUITE 307 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191523039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2677311333 | ||||||||
| FaxNumber: | 2677311284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 02/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | WOOD | ||||||||
| AuthorizedOfficialFirstName: | DEIRDRE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2677311333 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207N00000X | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 7018518 | 01 | PA | AETNA | OTHER |