Provider Demographics
NPI:1356415624
Name:WYATT, JAMES FOREST (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:FOREST
Last Name:WYATT
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 460
Mailing Address - Street 2:1905 EAST SUMMIT STREET
Mailing Address - City:RED OAK
Mailing Address - State:IA
Mailing Address - Zip Code:51566
Mailing Address - Country:US
Mailing Address - Phone:712-623-5416
Mailing Address - Fax:712-623-5418
Practice Address - Street 1:1905 EAST SUMMIT STREET
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:IA
Practice Address - Zip Code:51566
Practice Address - Country:US
Practice Address - Phone:712-623-5416
Practice Address - Fax:712-623-5418
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21247207V00000X
NE14435207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0180976Medicaid
18097OtherBCBSS
117393Medicare ID - Type UnspecifiedOPT OUT
18097OtherBCBSS