Provider Demographics
NPI:1427162585
Name:WOOTTON, DEVERE GARETH (MD)
Entity type:Individual
Prefix:
First Name:DEVERE
Middle Name:GARETH
Last Name:WOOTTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 20TH ST STE 470
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2090
Mailing Address - Country:US
Mailing Address - Phone:310-315-0222
Mailing Address - Fax:310-828-8852
Practice Address - Street 1:1301 20TH ST STE 470
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2090
Practice Address - Country:US
Practice Address - Phone:310-315-0222
Practice Address - Fax:310-828-8852
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG10008174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG10008Medicare PIN
CAA89139Medicare UPIN