Provider Demographics
NPI:1154371565
Name:WYMAN, MICHAEL LOUIS (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LOUIS
Last Name:WYMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 GASTON AVE
Mailing Address - Street 2:3HOB NEONATOLOGY
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-2096
Mailing Address - Country:US
Mailing Address - Phone:214-820-4012
Mailing Address - Fax:214-820-7757
Practice Address - Street 1:3500 GASTON AVE
Practice Address - Street 2:3HOB NEONATOLOGY
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2096
Practice Address - Country:US
Practice Address - Phone:214-820-4012
Practice Address - Fax:214-820-7757
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ59522080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP088E3884Medicaid
TX89576BMedicare ID - Type Unspecified
TXP088E3884Medicaid