Provider Demographics
NPI:1528374741
Name:TIMOTHY L WYATT MD PA
Entity Type:Organization
Organization Name:TIMOTHY L WYATT MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:LESTER
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-981-9959
Mailing Address - Street 1:2360A PARK ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4318
Mailing Address - Country:US
Mailing Address - Phone:904-981-9959
Mailing Address - Fax:904-981-9956
Practice Address - Street 1:2360A PARK ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4318
Practice Address - Country:US
Practice Address - Phone:904-981-9959
Practice Address - Fax:904-981-9956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-25
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64092207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty