Provider Demographics
NPI:1407820681
Name:WYNNE, JAMES W (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:WYNNE
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:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-273-8740
Mailing Address - Fax:352-392-0821
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-273-8740
Practice Address - Fax:352-392-0821
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0017582207RP1001X
FLME17582207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL052750500Medicaid
01978ZMedicare ID - Type Unspecified
01978YMedicare PIN
D50276Medicare UPIN