Provider Demographics
NPI:1336172741
Name:MICHAEL LEE WYNN MD INC
Entity Type:Organization
Organization Name:MICHAEL LEE WYNN MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-277-1055
Mailing Address - Street 1:5601 NORRIS CANYON RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583
Mailing Address - Country:US
Mailing Address - Phone:925-277-1055
Mailing Address - Fax:925-277-1915
Practice Address - Street 1:5601 NORRIS CANYON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583
Practice Address - Country:US
Practice Address - Phone:925-277-1055
Practice Address - Fax:925-277-1915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G398000208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A47970Medicare UPIN