Provider Demographics
NPI:1891004255
Name:RICHARD WOOTAN, MD,PA
Entity Type:Organization
Organization Name:RICHARD WOOTAN, MD,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOTAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-324-2824
Mailing Address - Street 1:8111 LBJ FWY
Mailing Address - Street 2:STE 835
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75251-1313
Mailing Address - Country:US
Mailing Address - Phone:972-644-3232
Mailing Address - Fax:972-644-7375
Practice Address - Street 1:9335 GARLAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75218-3639
Practice Address - Country:US
Practice Address - Phone:214-324-2824
Practice Address - Fax:214-324-2825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9034208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00SF96Medicare PIN