Provider Demographics
NPI:1518312818
Name:SNELLGROVE, WYATT CLIFTON DELONEY (DO)
Entity Type:Individual
Prefix:
First Name:WYATT CLIFTON
Middle Name:DELONEY
Last Name:SNELLGROVE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD
Mailing Address - Street 2:FL 2
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:
Practice Address - Street 1:12 PONDVIEW
Practice Address - Street 2:SUITE 101
Practice Address - City:PAINTED POST
Practice Address - State:NY
Practice Address - Zip Code:14870-9117
Practice Address - Country:US
Practice Address - Phone:251-504-1218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2019-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY298523207R00000X
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program