Provider Demographics
NPI:1134102569
Name:TO, WYATT CLARENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:WYATT
Middle Name:CLARENCE
Last Name:TO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:63 THOMAS JOHNSON DR
Mailing Address - Street 2:STE B
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4396
Mailing Address - Country:US
Mailing Address - Phone:240-446-4035
Mailing Address - Fax:
Practice Address - Street 1:63 THOMAS JOHNSON DR
Practice Address - Street 2:SUITE
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4384
Practice Address - Country:US
Practice Address - Phone:301-698-2424
Practice Address - Fax:301-698-1018
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM559872082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD548RMedicare ID - Type Unspecified
MDH74641Medicare UPIN