Provider Demographics
NPI:1730317652
Name:WOOTEN, CLINT JOHN (MD)
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:JOHN
Last Name:WOOTEN
Suffix:
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 1:1551 S. RENAISSANCE TOWNE DRIVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BOUNTIUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7272
Mailing Address - Country:US
Mailing Address - Phone:801-295-7200
Mailing Address - Fax:
Practice Address - Street 1:1551 RENAISSANCE TOWNE DR
Practice Address - Street 2:SUITE 400
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7667
Practice Address - Country:US
Practice Address - Phone:801-295-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5506567-1205207X00000X
MN53240207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0397730024Medicare NSC
NC1730317652Medicaid
SCNC2095Medicaid
NCNCI802AMedicare PIN