Provider Demographics
NPI:1316903099
Name:WAYT, MARTA JEAN (DO)
Entity type:Individual
Prefix:
First Name:MARTA
Middle Name:JEAN
Last Name:WAYT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:
Practice Address - Street 1:111 W STONE DR STE 200
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-6028
Practice Address - Country:US
Practice Address - Phone:423-723-2030
Practice Address - Fax:423-247-4110
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO01541207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNTN01R2OtherJOHN DEERE
TN3307865Medicaid
TN4066478OtherBCBS
TN3307865Medicaid
TN103I119270Medicare PIN
TN4066478OtherBCBS