Provider Demographics
NPI:1124187448
Name:SMITH, WYATT S (DO)
Entity Type:Individual
Prefix:DR
First Name:WYATT
Middle Name:S
Last Name:SMITH
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 1:6759 BRONZE POST RD
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2189
Mailing Address - Country:US
Mailing Address - Phone:703-222-8807
Mailing Address - Fax:
Practice Address - Street 1:8901 ROCKVILLE PIKE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-5600
Practice Address - Country:US
Practice Address - Phone:301-295-4810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A 5297207RH0003X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Not Answered207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology