Provider Demographics
NPI:1922240019
Name:WYATT, ROBERT E (DPM)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:WYATT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9134 BRADENTON RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-8892
Mailing Address - Country:US
Mailing Address - Phone:260-715-5906
Mailing Address - Fax:
Practice Address - Street 1:9134 BRADENTON RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-8892
Practice Address - Country:US
Practice Address - Phone:260-715-5906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000599A213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine