Provider Demographics
NPI:1558380410
Name:WYATT, THOMAS HARRIS (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:HARRIS
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:PO BOX 850489
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36685-0489
Mailing Address - Country:US
Mailing Address - Phone:251-342-3949
Mailing Address - Fax:251-631-3361
Practice Address - Street 1:5571 HIGHWAY 43 NORTH
Practice Address - Street 2:
Practice Address - City:SATSUMA
Practice Address - State:AL
Practice Address - Zip Code:36572-0108
Practice Address - Country:US
Practice Address - Phone:251-675-2029
Practice Address - Fax:251-675-3734
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00005880174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL511-16920OtherBLUE CROSS BLUE SHIELD OF ALABAMA
AL133632Medicaid
051523637OtherBC BS OF ALABAMA PROVIDER
AL133632Medicaid
AL102I012856Medicare PIN