Healthcare Provider Details

I. General information

NPI: 1376694802
Provider Name (Legal Business Name): WILMA JEAN WOOTEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 PACIFIC HWY STE 311
SAN DIEGO CA
92101-2417
US

IV. Provider business mailing address

1700 PACIFIC HWY STE 311
SAN DIEGO CA
92101-2417
US

V. Phone/Fax

Practice location:
  • Phone: 619-515-6519
  • Fax: 619-515-6527
Mailing address:
  • Phone: 619-515-6519
  • Fax: 619-515-6527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberA46474
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: