Provider Demographics
NPI:1356310486
Name:WYNN, MARY E (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:WYNN
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 1:1061 HARMON AVE
Mailing Address - Street 2:SUITE 1D03
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5641
Mailing Address - Country:US
Mailing Address - Phone:912-435-6633
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVE
Practice Address - Street 2:SUITE 1D03
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5641
Practice Address - Country:US
Practice Address - Phone:912-435-6633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36.12214207Q00000X
OH35.061059207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0837670Medicaid
OH0837670Medicaid
OHW40803014Medicare ID - Type Unspecified