Provider Demographics
NPI:1245305234
Name:WYNNE, SUSAN K (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:WYNNE
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 1:16007 VIA SHAVANO
Mailing Address - Street 2:STE. 101
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249
Mailing Address - Country:US
Mailing Address - Phone:210-615-8900
Mailing Address - Fax:210-615-9400
Practice Address - Street 1:16007 VIA SHAVANO
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249
Practice Address - Country:US
Practice Address - Phone:210-615-8900
Practice Address - Fax:210-615-9400
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK11412084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX828110Medicare ID - Type Unspecified
TX744GMedicare ID - Type Unspecified
G32988Medicare UPIN