Provider Demographics
NPI:1801984497
Name:WOTHERSPOON, REBECCA J (MD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:J
Last Name:WOTHERSPOON
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:101 S PARK LN
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-5731
Mailing Address - Country:US
Mailing Address - Phone:580-379-6100
Mailing Address - Fax:580-379-6109
Practice Address - Street 1:222 E PRIMROSE ST
Practice Address - Street 2:SUITE E
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5206
Practice Address - Country:US
Practice Address - Phone:417-553-1080
Practice Address - Fax:888-712-7702
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2015-08-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO102581208000000X
OK29631208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200014010BMedicaid
MO202710364Medicaid
OK277004YMXAMedicare PIN
MO202710364Medicaid