Provider Demographics
NPI:1073788956
Name:WYATT, COLBY A (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:COLBY
Middle Name:A
Last Name:WYATT
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:301C US ROUTE ONE
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:887 CONGRESS ST
Practice Address - Street 2:SUITE 320
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102
Practice Address - Country:US
Practice Address - Phone:207-662-5522
Practice Address - Fax:207-662-5527
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MEMD195912080P0214X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME003351701Medicare PIN