Healthcare Provider Details

I. General information

NPI: 1629464912
Provider Name (Legal Business Name): MELANIE SUSANNAH WOOTEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1199 PRINCE AVE
ATHENS GA
30606-2797
US

IV. Provider business mailing address

5700 SOUTHWYCK BLVD
TOLEDO OH
43614-1509
US

V. Phone/Fax

Practice location:
  • Phone: 706-475-7000
  • Fax:
Mailing address:
  • Phone: 800-288-8325
  • Fax: 419-866-5453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number79582
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License Number79582
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: