Provider Demographics
NPI:1801809439
Name:WYATT, DOUGLAS B (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:B
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 1:3501 S SONCY RD STE 109
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119-6405
Mailing Address - Country:US
Mailing Address - Phone:806-467-2888
Mailing Address - Fax:806-467-2999
Practice Address - Street 1:3501 S SONCY RD STE 109
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79119-6405
Practice Address - Country:US
Practice Address - Phone:806-467-2888
Practice Address - Fax:806-467-2999
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG9018208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX035017501Medicaid
TX00N46HOtherBCBS OF TEXAS
TXTXB121405Medicare PIN
TX035017501Medicaid