Provider Demographics
NPI:1558306761
Name:WOOTEN, SALLY M (MD)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:M
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5098
Mailing Address - Country:US
Mailing Address - Phone:615-920-7906
Mailing Address - Fax:615-920-8938
Practice Address - Street 1:927 KENTON STATION DR
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-9617
Practice Address - Country:US
Practice Address - Phone:606-759-0433
Practice Address - Fax:606-759-0058
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46724207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100269150Medicaid
PA001087464Medicaid
SC1558306761Medicaid
SCAA31868989OtherMEDICARE PTAN
SC1558306761Medicaid
SCAA31868989OtherMEDICARE PTAN
VAGC1100Medicare PIN