Basic Information
| Provider Information | |||||||||
| NPI: | 1932131745 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOOTEN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1540 SUNDAY DR | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276076000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197823456 | ||||||||
| FaxNumber: | 9197877552 | ||||||||
| Practice Location | |||||||||
| Address1: | 1520 SUNDAY DR | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276075253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197823456 | ||||||||
| FaxNumber: | 9197877552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 01/13/2011 | ||||||||
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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 | 2084N0402X | 30263 | NC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
| ID | Type | State | Issuer | Description | 8912399 | 05 | NC | MEDICAID |