Provider Demographics
NPI:1497731640
Name:WYNE, KATHLEEN L (MD, PHD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:L
Last Name:WYNE
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-685-3333
Mailing Address - Fax:
Practice Address - Street 1:543 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43203-1278
Practice Address - Country:US
Practice Address - Phone:614-685-3333
Practice Address - Fax:614-366-0345
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3004207RE0101X
OH35.124567207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX036834203Medicaid
TXPO80133K5Medicaid
TXDE4842OtherRAILROAD MEDICARE
LA2122240Medicaid
TX036834205Medicaid
TX8V4457OtherBLUE CROSS BLUE SHIELD
OH0116849Medicaid
WY080133KMedicare ID - Type Unspecified
LA2122240Medicaid
TX036834203Medicaid