Provider Demographics
NPI:1588654727
Name:WOOTEN, DAVID JR (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:WOOTEN
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 S MARKET BLVD
Mailing Address - Street 2:PO BOX 1245
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-3037
Mailing Address - Country:US
Mailing Address - Phone:360-748-9700
Mailing Address - Fax:
Practice Address - Street 1:123 S MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3037
Practice Address - Country:US
Practice Address - Phone:360-748-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001802207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8298440Medicaid
WA7114812Medicaid
WAH51308Medicare UPIN
WAGAB37936Medicare ID - Type Unspecified