Provider Demographics
NPI:1487844585
Name:WYATT, JONATHAN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DAVID
Last Name:WYATT
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 1:800 FAIR PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-1720
Mailing Address - Country:US
Mailing Address - Phone:501-978-2623
Mailing Address - Fax:
Practice Address - Street 1:800 FAIR PARK BLVD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204
Practice Address - Country:US
Practice Address - Phone:501-604-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRS2011-0385207X00000X
ARE-7431207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR192471001Medicaid
AR192471001Medicaid