Basic Information
| Provider Information | |||||||||
| NPI: | 1083678510 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOOTTEN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5780 PEACHTREE DUNWOODY ROAD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043031224 | ||||||||
| FaxNumber: | 4043031325 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 JOHNSON FERRY RD | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042521137 | ||||||||
| FaxNumber: | 4042526794 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 08/08/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 035790 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 000692887Z | 05 | GA | MEDICAID | 000692887AA | 05 | GA | MEDICAID | 000692887AE | 05 | GA | MEDICAID | 000692887AF | 05 | GA | MEDICAID |