Provider Demographics
NPI:1609053198
Name:OWENS, WYTHE WYNDHAM III (MD)
Entity Type:Individual
Prefix:DR
First Name:WYTHE
Middle Name:WYNDHAM
Last Name:OWENS
Suffix:III
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 11167
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37939-1167
Mailing Address - Country:US
Mailing Address - Phone:865-584-7376
Mailing Address - Fax:
Practice Address - Street 1:1420 TUSCULUM BLVD
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-4279
Practice Address - Country:US
Practice Address - Phone:423-787-5021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0014852085R0202X
TN507462085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ006178Medicaid
TNQ006178Medicaid