Provider Demographics
NPI:1114920972
Name:WYRICK, SCOTT W (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:W
Last Name:WYRICK
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 1:3333 POTOMAC AVE
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-3513
Mailing Address - Country:US
Mailing Address - Phone:903-792-3787
Mailing Address - Fax:903-792-0446
Practice Address - Street 1:3333 POTOMAC AVE
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3513
Practice Address - Country:US
Practice Address - Phone:903-792-3787
Practice Address - Fax:903-792-0446
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2424207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80451YOtherBLUE CROSS
TXT0120358OtherCONTROLLED SUBSTANCES REG
TX070016709OtherMEDICARE RAILROAD
TX150168601Medicaid
TX8312J1OtherMEDICARE
AR99096OtherBLUE CROSS
AR148032001Medicaid
AR148032001Medicaid
TX070016709OtherMEDICARE RAILROAD