Provider Demographics
NPI:1568154680
Name:WOOTEN, DERRICK EARL
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:EARL
Last Name:WOOTEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 MISSION BOULEVARD
Mailing Address - Street 2:305
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230
Mailing Address - Country:US
Mailing Address - Phone:443-929-4522
Mailing Address - Fax:
Practice Address - Street 1:3423 5TH ST SE APT 12
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-5443
Practice Address - Country:US
Practice Address - Phone:202-554-2199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant