Basic Information
| Provider Information | |||||||||
| NPI: | 1407173016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOOTTON | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 845347 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752847208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146365555 | ||||||||
| FaxNumber: | 4237783146 | ||||||||
| Practice Location | |||||||||
| Address1: | 6201 HARRY HINES BLVD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753902147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146335555 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2010 | ||||||||
| LastUpdateDate: | 09/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 48047 | TN | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | S1735 | TX | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 1531864 | 05 | TN | MEDICAID |