Provider Demographics
NPI:1881780393
Name:WOOTTEN, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WOOTTEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:720 WASHIGNTON AVE SE
Mailing Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414
Mailing Address - Country:US
Mailing Address - Phone:612-884-0649
Mailing Address - Fax:
Practice Address - Street 1:1020 WEST BROADWAY
Practice Address - Street 2:UMP-BROADWAY FAMILY MEDICINE
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411
Practice Address - Country:US
Practice Address - Phone:612-302-8200
Practice Address - Fax:612-302-8275
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN30205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN768417OtherARAZ
MN01-12683OtherMEDICA - PRIMARY
MNHP27070OtherHEALTHPARTNERS
MN0190027OtherPREFERREDONE
MN36A76WOOtherBLUE CROSS BLUE SHIELD
MN01-12683OtherMEDICA - CHOICE
MN109253OtherUCARE
MN059550OtherFAIRVIEW
MNE34343Medicare UPIN
MN768417OtherARAZ
MN269363100Medicare ID - Type Unspecified