Provider Demographics
NPI:1962510040
Name:WYNN, STEVEN W (MD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:W
Last Name:WYNN
Suffix:
Gender:M
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-786-7500
Mailing Address - Fax:
Practice Address - Street 1:2400 NORTH WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:N OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84414-7233
Practice Address - Country:US
Practice Address - Phone:801-387-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2942391205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
005531303Medicare PIN
005509316Medicare PIN
F84858Medicare UPIN
UT000063709Medicare PIN