Provider Demographics
NPI:1013919471
Name:WYNN, MICHAEL HANLON (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:HANLON
Last Name:WYNN
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 1:23972A HIGHWAY 59 N
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-1535
Mailing Address - Country:US
Mailing Address - Phone:281-540-1444
Mailing Address - Fax:281-446-5865
Practice Address - Street 1:23972A HIGHWAY 59 N
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-1535
Practice Address - Country:US
Practice Address - Phone:281-540-1444
Practice Address - Fax:281-432-5865
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDP0780213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112230102Medicaid
T16763Medicare UPIN
TX112230102Medicaid