Provider Demographics
NPI:1346311677
Name:WYATT, DAVID A (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:WYATT
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 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5715
Mailing Address - Fax:
Practice Address - Street 1:2001 CRYSTAL SPRING AVE SW STE 201
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-2465
Practice Address - Country:US
Practice Address - Phone:540-853-0100
Practice Address - Fax:540-342-9308
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98555208G00000X
TN29821208G00000X
VA0101037626208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNDB4643OtherRAILROAD MEDICARE
TN3820393Medicaid
TNP00107052OtherRAILROAD MEDICARE
FL278324000Medicaid
TN3723206Medicaid
TN4070506OtherBCBSTN
TN3723206Medicare ID - Type Unspecified
TN3820393Medicare ID - Type Unspecified
TNDB4643OtherRAILROAD MEDICARE
TN3820393Medicaid