MEDICARE: EDWARD WRENN WOOTEN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	L4179	TX
2	2085R0202X	Diagnostic Radiology Physician	E3681	AR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8K6572	OTHER	TX	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144217373
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD WRENN WOOTEN MD

Provider Business Mailing Address
First Line	:	PO BOX 1523
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72702-1523
Country	:	US
Telephone Number	:	479-571-6038
Fax Number	:	479-582-0222

Provider Business Practice Location Address
First Line	:	3344 N FUTRALL DR
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72703-4057
Country	:	US
Telephone Number	:	479-443-5316
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2005
Last Update Date	:	08/19/2024

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Directions to “ EDWARD WRENN WOOTEN MD” Practice Location

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