Provider Demographics
NPI:1497866040
Name:WYNN, VANDER M (MD)
Entity Type:Individual
Prefix:
First Name:VANDER
Middle Name:M
Last Name:WYNN
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 1:5309 WATERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34291-8032
Mailing Address - Country:US
Mailing Address - Phone:239-261-1158
Mailing Address - Fax:239-261-4232
Practice Address - Street 1:5309 WATERVIEW DR
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34291-8032
Practice Address - Country:US
Practice Address - Phone:239-261-1158
Practice Address - Fax:239-261-4232
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66148207L00000X
NY281372207L00000X
GA075180207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
050029800OtherRAILROAD MEDICARE
FL375454500Medicaid
FL25438OtherBLUE CROSS BLUE SHIELD OF FL
BW4034752OtherDEA
FL25438Medicare ID - Type Unspecified
FL25438OtherBLUE CROSS BLUE SHIELD OF FL
FL25438NMedicare PIN