Provider Demographics
NPI:1982340667
Name:DP WYATT LLC
Entity Type:Organization
Organization Name:DP WYATT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:POWELL
Authorized Official - Middle Name:B
Authorized Official - Last Name:AUER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-990-9099
Mailing Address - Street 1:PO BOX 5237
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-5237
Mailing Address - Country:US
Mailing Address - Phone:318-798-4539
Mailing Address - Fax:
Practice Address - Street 1:708 NORTH ASHLEY RIDGE LOOP BUILDING 400
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106
Practice Address - Country:US
Practice Address - Phone:318-698-7000
Practice Address - Fax:318-698-7006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1305171Medicaid