Healthcare Provider Details

I. General information

NPI: 1548220320
Provider Name (Legal Business Name): DONALD DWIGHT WOTHE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 28TH ST
MINNEAPOLIS MN
55407-3723
US

IV. Provider business mailing address

PO BOX 43 MR 10809
MINNEAPOLIS MN
55440-0043
US

V. Phone/Fax

Practice location:
  • Phone: 612-863-4502
  • Fax: 612-863-5697
Mailing address:
  • Phone: 612-262-4813
  • Fax: 612-262-4194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number12214
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number40621
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number12214
License Number StateND
# 4
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number40621
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: