Provider Demographics
NPI:1356649131
Name:DOUGLAS B WYATT MD PA
Entity Type:Organization
Organization Name:DOUGLAS B WYATT MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR, GENERAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:B
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:806-467-2888
Mailing Address - Street 1:3501 S SONCY RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119-6407
Mailing Address - Country:US
Mailing Address - Phone:806-467-2888
Mailing Address - Fax:806-467-2999
Practice Address - Street 1:3501 S SONCY RD STE 109
Practice Address - Street 2:SUITE 109
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79119-6405
Practice Address - Country:US
Practice Address - Phone:806-467-2888
Practice Address - Fax:806-467-2999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-03
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG9018208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB121404Medicare PIN