Provider Demographics
NPI:1871943472
Name:WOOD, THOMAS
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:WOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 W ROCKTON RD
Mailing Address - Street 2:
Mailing Address - City:ROCKTON
Mailing Address - State:IL
Mailing Address - Zip Code:61072-1631
Mailing Address - Country:US
Mailing Address - Phone:815-624-8431
Mailing Address - Fax:
Practice Address - Street 1:2990 N PERRYVILLE RD UNIT 1100
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6827
Practice Address - Country:US
Practice Address - Phone:779-220-2147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2023-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
IL1871943472174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist