Provider Demographics
NPI:1215147707
Name:WOOTEN, ERIC TYLER (DO)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:TYLER
Last Name:WOOTEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12909
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77726-2909
Mailing Address - Country:US
Mailing Address - Phone:409-899-8501
Mailing Address - Fax:409-899-8510
Practice Address - Street 1:2965 HARRISON ST STE 211
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1149
Practice Address - Country:US
Practice Address - Phone:409-899-8501
Practice Address - Fax:409-899-8510
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4849208600000X, 2086S0127X
OH58-001323208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX211211201Medicaid
TX8L25028Medicare PIN