Provider Demographics
NPI:1720252927
Name:WOOTAN, GEORGE ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:ALLEN
Last Name:WOOTAN
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 1:4379 ROUTE 28A
Mailing Address - Street 2:
Mailing Address - City:WEST SHOKAN
Mailing Address - State:NY
Mailing Address - Zip Code:12494-5110
Mailing Address - Country:US
Mailing Address - Phone:845-704-7046
Mailing Address - Fax:
Practice Address - Street 1:4379 ROUTE 28A
Practice Address - Street 2:
Practice Address - City:WEST SHOKAN
Practice Address - State:NY
Practice Address - Zip Code:12494-5110
Practice Address - Country:US
Practice Address - Phone:845-704-7046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096518207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine