Basic Information
| Provider Information | |||||||||
| NPI: | 1730317652 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOOTEN | ||||||||
| FirstName: | CLINT | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1551 S. RENAISSANCE TOWNE DRIVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | BOUNTIUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840107272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012957200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1551 RENAISSANCE TOWNE DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840107667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012957200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2009 | ||||||||
| LastUpdateDate: | 10/14/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 5506567-1205 | UT | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.