Provider Demographics
NPI:1326024902
Name:WYATT, KIMBERLY SUE (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:SUE
Last Name:WYATT
Suffix:
Gender:F
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 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-2832
Mailing Address - Fax:772-223-5665
Practice Address - Street 1:509 SE RIVERSIDE DR STE 303
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2579
Practice Address - Country:US
Practice Address - Phone:772-283-9111
Practice Address - Fax:772-781-2785
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121614207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIBWUZOtherFLORIDA BLUE
FL016279500Medicaid
FL016279500Medicaid