Provider Demographics
NPI:1992709604
Name:WOOD, GARY LEE (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
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 1:19020 33RD AVE W STE 210
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4748
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:3900 CAPITAL MALL DR SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8654
Practice Address - Country:US
Practice Address - Phone:360-754-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD604036562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2030512Medicaid
AZ537764Medicaid
NM52713Medicaid
NM72785Medicaid
NM2258272OtherMEDICARE GROUP
AZ537764Medicaid
NML0634Medicaid
NM45138Medicaid
NM800521126OtherMEDICARE IDTF
AZZ130652Medicare PIN
NM52713Medicaid
NMRADIA027Medicare PIN