Provider Demographics
NPI:1841641974
Name:WOOTEN, TONDA RENEE (DPM)
Entity type:Individual
Prefix:
First Name:TONDA
Middle Name:RENEE
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:TONDA
Other - Middle Name:
Other - Last Name:WOOTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4660 RIVERSIDE PARK BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1399
Mailing Address - Country:US
Mailing Address - Phone:478-474-2114
Mailing Address - Fax:478-474-8001
Practice Address - Street 1:4660 RIVERSIDE PARK BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1395
Practice Address - Country:US
Practice Address - Phone:478-474-2114
Practice Address - Fax:478-474-8745
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ000000213ES0103X
KY00451213ES0103X
GAPOD001462213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00451OtherKENTUCKY STATE LICENSE