Provider Demographics
NPI:1679575203
Name:WOOD, STACEY A JR (MD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:WOOD
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-5270
Mailing Address - Fax:704-316-5271
Practice Address - Street 1:1718 E 4TH ST
Practice Address - Street 2:SUITE 707
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3261
Practice Address - Country:US
Practice Address - Phone:704-316-5270
Practice Address - Fax:704-316-5271
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC31407207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8988947Medicaid
NC211682DMedicare PIN
NC211682CMedicare PIN
NC8988947Medicaid