Provider Demographics
NPI:1407896327
Name:WYATT, LEWIS JR (MD)
Entity Type:Individual
Prefix:MR
First Name:LEWIS
Middle Name:
Last Name:WYATT
Suffix:JR
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 1:8631 W 3RD ST
Mailing Address - Street 2:1125 E
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5109
Mailing Address - Country:US
Mailing Address - Phone:310-360-7430
Mailing Address - Fax:310-360-7435
Practice Address - Street 1:8631 W 3RD ST
Practice Address - Street 2:1125 E
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5109
Practice Address - Country:US
Practice Address - Phone:310-360-7430
Practice Address - Fax:310-360-7435
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC32030207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A87549Medicare UPIN
CA00C320300Medicare ID - Type Unspecified