Provider Demographics
NPI:1811073794
Name:WYNN, JAMES LAWRENCE (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:LAWRENCE
Last Name:WYNN
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 1:1600 SW ARCHER RD
Mailing Address - Street 2:PO BOX 100296
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0296
Mailing Address - Country:US
Mailing Address - Phone:352-273-8985
Mailing Address - Fax:352-273-9054
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-0296
Practice Address - Country:US
Practice Address - Phone:352-273-8985
Practice Address - Fax:352-273-9054
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 1239622080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014830000Medicaid
FLIE179ZMedicare PIN