Provider Demographics
NPI:1275893950
Name:KAELIN WOOTON, KATHLEEN M (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:M
Last Name:KAELIN WOOTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KATHLEEN
Other - Middle Name:M
Other - Last Name:KAELIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:223 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-2245
Mailing Address - Country:US
Mailing Address - Phone:201-964-1806
Mailing Address - Fax:
Practice Address - Street 1:223 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070-2245
Practice Address - Country:US
Practice Address - Phone:201-964-1806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07176200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine