Provider Demographics
NPI:1972569051
Name:WOOTON, BRIAN DOUGLAS (DO)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:DOUGLAS
Last Name:WOOTON
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 1:801 SOUTH DR
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103
Mailing Address - Country:US
Mailing Address - Phone:701-235-2805
Mailing Address - Fax:
Practice Address - Street 1:40520 CO HWY 34
Practice Address - Street 2:WHITE EARTH HEALTH CENTER
Practice Address - City:OGEMA
Practice Address - State:MN
Practice Address - Zip Code:56569
Practice Address - Country:US
Practice Address - Phone:218-983-4300
Practice Address - Fax:218-983-6217
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47147207Q00000X
ND8642207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
351G7W0OtherBCBS
585241027376OtherPREFERRED ONE
G37190Medicare UPIN