Provider Demographics
NPI:1992841886
Name:WYATT- KIRKPATRICK EYE MD ASSOCIATES
Entity Type:Organization
Organization Name:WYATT- KIRKPATRICK EYE MD ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MIMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-874-3403
Mailing Address - Street 1:2 OFFICE PARK CIR
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701-6538
Mailing Address - Country:US
Mailing Address - Phone:334-872-3403
Mailing Address - Fax:334-872-3405
Practice Address - Street 1:2 OFFICE PARK CIR
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-6538
Practice Address - Country:US
Practice Address - Phone:334-872-3403
Practice Address - Fax:334-872-3405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-B10-TA-704152W00000X
AL20641207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009937627Medicaid
AL051002044OtherBCBS
AL051525773OtherBCBS
V06937OtherUPIN
118255OtherEYEMED
G68704OtherUPIN
P00437321OtherRAILROAD MEDICARE
G68704OtherVIVA HEALTH MEDICARE
AL009976795Medicaid
180035890OtherRAILROAD MEDICARE
AL000002044Medicaid
AL051535830OtherDR. MUTAI BCBS
G68704OtherVIVA HEALTH MEDICARE
118255OtherEYEMED
ALG68704Medicare UPIN
1258000001Medicare NSC
V06937OtherUPIN
AL009976795Medicaid
000002044Medicare PIN