Provider Demographics
NPI:1427134675
Name:WOOTON, AMY NOEL (MD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:NOEL
Last Name:WOOTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:330 N MAIN ST
Mailing Address - Street 2:SUITE 101-102
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4465
Mailing Address - Country:US
Mailing Address - Phone:937-433-0960
Mailing Address - Fax:937-433-0958
Practice Address - Street 1:330 N MAIN ST
Practice Address - Street 2:SUITE 101-102
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4465
Practice Address - Country:US
Practice Address - Phone:937-433-0960
Practice Address - Fax:937-433-0958
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35085253207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2211609Medicaid
OH2211609Medicaid
OH4175341Medicare PIN
OH147483Medicare UPIN
OHH346870Medicare PIN