Provider Demographics
NPI:1558456632
Name:WYANT, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WYANT
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 1:7151 MARSH RD STE 150
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-1631
Mailing Address - Country:US
Mailing Address - Phone:317-293-4113
Mailing Address - Fax:317-290-2542
Practice Address - Street 1:7151 MARSH RD STE 150
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-1631
Practice Address - Country:US
Practice Address - Phone:317-293-4113
Practice Address - Fax:317-290-2542
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035396207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1000069000Medicaid
IN151560G1Medicare PIN
IN1000069000Medicaid
IN1000069000Medicaid
IN152520JMedicare PIN