Provider Demographics
NPI:1699055236
Name:WOOD, JONATHAN STEPHEN (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:STEPHEN
Last Name:WOOD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 FIVE FORKS TRICKUM RD SW STE 102
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-8975
Mailing Address - Country:US
Mailing Address - Phone:770-923-6400
Mailing Address - Fax:
Practice Address - Street 1:4120 FIVE FORKS TRICKUM RD SW STE 102
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-8975
Practice Address - Country:US
Practice Address - Phone:770-923-6400
Practice Address - Fax:770-676-9876
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-26
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA76998208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003172167Medicaid
GA76998OtherGEORGIA MEDICAL LICENSE
GA003172167HMedicaid
GA003172167JMedicaid
GA003172167MMedicaid
GA003172167NMedicaid
GA1707074OtherWELLCARE
GA003172167LMedicaid
GA06047829OtherAMERIGROUP
GA003172167KMedicaid
GA003172167IMedicaid