Provider Demographics
NPI:1114184249
Name:WOOTTON, JAMES L III (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:L
Last Name:WOOTTON
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 511
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MS
Mailing Address - Zip Code:39645-0511
Mailing Address - Country:US
Mailing Address - Phone:601-657-4326
Mailing Address - Fax:601-657-8867
Practice Address - Street 1:300 RAWLS DR STE 1300
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2866
Practice Address - Country:US
Practice Address - Phone:601-249-3541
Practice Address - Fax:601-249-3544
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25172207Q00000X
LA203810207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05039502Medicaid