1952379919 NPI number — STEVEN W. WOOD IDC

Table of content: DR. FONDA R PEDERSEN D.D.S. (NPI 1295950996)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952379919 NPI number — STEVEN W. WOOD IDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOOD
Provider First Name:
STEVEN
Provider Middle Name:
W.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
IDC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952379919
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 RYLAND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STAFFORD
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22556-1266
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-286-1940
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NAVAL HEALTH CLINIC QUANTICO
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
QUANTICO
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22134-6050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-784-5541
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1710I1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1710I1002X . This is a "INDEPENDENT DUTY CORPSMAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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