Provider Demographics
NPI:1922016534
Name:WYATT, GREGORY M (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:M
Last Name:WYATT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:42217 RIO NEDO
Mailing Address - Street 2:A203
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-3729
Mailing Address - Country:US
Mailing Address - Phone:951-296-6140
Mailing Address - Fax:951-296-6149
Practice Address - Street 1:25500 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5965
Practice Address - Country:US
Practice Address - Phone:951-296-6140
Practice Address - Fax:951-296-6149
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG26574207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G265740Medicare ID - Type Unspecified