Provider Demographics
NPI:1114993102
Name:MCNEILL, WYATT (MD)
Entity Type:Individual
Prefix:DR
First Name:WYATT
Middle Name:
Last Name:MCNEILL
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:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:UFJP OB/GYN
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-3408
Practice Address - Fax:904-244-3124
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME12384207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00224904OtherRAILROAD MEDICARE
FL2724073-00Medicaid
GA000875179AMedicaid
FL259260600Medicaid
FL259260600Medicaid
FLD53050Medicare UPIN
FL2724073-00Medicaid