Provider Demographics
NPI:1306823604
Name:WYATT, MICHAEL D (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:WYATT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:6440 W NEWBERRY RD
Mailing Address - Street 2:STE 402
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605
Mailing Address - Country:US
Mailing Address - Phone:352-333-5500
Mailing Address - Fax:352-333-5506
Practice Address - Street 1:6440 W NEWBERRY RD
Practice Address - Street 2:STE 402
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4381
Practice Address - Country:US
Practice Address - Phone:352-333-5500
Practice Address - Fax:352-333-5506
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-28
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME0070937208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
E82464Medicare UPIN