Provider Demographics
NPI:1770782849
Name:DECATUR DERMATOLOGY, PC
Entity type:Organization
Organization Name:DECATUR DERMATOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-353-7775
Mailing Address - Street 1:620 WALNUT STREET NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-2456
Mailing Address - Country:US
Mailing Address - Phone:256-353-7775
Mailing Address - Fax:256-353-7765
Practice Address - Street 1:620 WALNUT STREET NE
Practice Address - Street 2:SUITE A
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-2456
Practice Address - Country:US
Practice Address - Phone:256-353-7775
Practice Address - Fax:256-353-7765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529924440Medicaid