Provider Demographics
NPI:1942247150
Name:WYATT, SAMANTHA S (MD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:S
Last Name:WYATT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 WALNUT ST 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 ST 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
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00026547207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009932289Medicaid
AL51001088OtherBCBS AL PROVIDER#
AL529924440Medicaid
AL009932289Medicaid
AL5299924440Medicare NSC
ALI25671Medicare UPIN