Provider Demographics
NPI:1780039859
Name:HYATT, WILFORD (MSED)
Entity Type:Individual
Prefix:
First Name:WILFORD
Middle Name:
Last Name:HYATT
Suffix:
Gender:M
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 ELZEY AVE
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-1529
Mailing Address - Country:US
Mailing Address - Phone:646-621-0331
Mailing Address - Fax:516-706-7045
Practice Address - Street 1:220 ELZEY AVE
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-1529
Practice Address - Country:US
Practice Address - Phone:646-621-0331
Practice Address - Fax:516-706-7045
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist