Provider Demographics
NPI:1750332516
Name:WYNN, MICHAEL L I (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:WYNN
Suffix:I
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 1:1655 LIBERTY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4347
Mailing Address - Country:US
Mailing Address - Phone:503-581-7959
Mailing Address - Fax:503-362-4114
Practice Address - Street 1:1655 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4347
Practice Address - Country:US
Practice Address - Phone:503-581-7959
Practice Address - Fax:503-362-4114
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO156952084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR203505Medicaid
OR203505Medicaid