Provider Demographics
NPI:1740287630
Name:WYATT, CHARLES HANDFIELD (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:HANDFIELD
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 11407 DEPT # 8094
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-0001
Mailing Address - Country:US
Mailing Address - Phone:251-410-4002
Mailing Address - Fax:251-410-4001
Practice Address - Street 1:3715 DAUPHIN ST STE 7A
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-1775
Practice Address - Country:US
Practice Address - Phone:251-410-4001
Practice Address - Fax:251-410-4002
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64289208G00000X
ALMD41701208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAF75290Medicare UPIN
LA330004743OtherRR MEDICARE
LA1536695Medicaid
LA5A325Medicare PIN