Healthcare Provider Details

I. General information

NPI: 1801984497
Provider Name (Legal Business Name): REBECCA J WOTHERSPOON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 E PRIMROSE ST SUITE E
SPRINGFIELD MO
65807-5206
US

IV. Provider business mailing address

101 S PARK LN
ALTUS OK
73521-5731
US

V. Phone/Fax

Practice location:
  • Phone: 417-553-1080
  • Fax: 888-712-7702
Mailing address:
  • Phone: 580-379-6100
  • Fax: 580-379-6109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number102581
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number29631
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200014010B
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer
# 2
Identifier202710364
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: