Provider Demographics
NPI:1457443186
Name:DOUGLAS F WYNNE MD
Entity Type:Organization
Organization Name:DOUGLAS F WYNNE MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WYNNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-671-7100
Mailing Address - Street 1:2950 SQUALICUM PKWY
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1857
Mailing Address - Country:US
Mailing Address - Phone:360-671-7100
Mailing Address - Fax:
Practice Address - Street 1:2950 SQUALICUM PKWY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1857
Practice Address - Country:US
Practice Address - Phone:360-671-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1954908Medicaid
WA1954908Medicaid