Basic Information
| Provider Information | |||||||||
| NPI: | 1548220320 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOTHE | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | DWIGHT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 43 | ||||||||
| Address2: | MR 10809 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554400043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122624813 | ||||||||
| FaxNumber: | 6122624194 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 E 28TH ST | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554073723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128634502 | ||||||||
| FaxNumber: | 6128635697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 12214 | ND | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 40621 | MN | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VM0101X | 12214 | ND | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 207VM0101X | 40621 | MN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 913019500 | 05 | MN | MEDICAID |