Provider Demographics
NPI:1316906696
Name:WYATT, WENDELL DEAN (MD)
Entity type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:DEAN
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 1:34482 PASEO REAL
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-6766
Mailing Address - Country:US
Mailing Address - Phone:413-775-3347
Mailing Address - Fax:
Practice Address - Street 1:34482 PASEO REAL
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-6766
Practice Address - Country:US
Practice Address - Phone:413-775-3347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2024-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC136244207R00000X, 207R00000X
CA136244207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2113295Medicaid
H45959Medicare UPIN
MAA39471Medicare PIN
MA1316906696OtherBMC
MA1316906696OtherFALLON
MA225422OtherCONNECTICARE
MA37012OtherHNE
MA7912269OtherAETNA
MA2113295Medicaid
MA042945394OtherPINNACLE HEALTH
H45959Medicare UPIN
MA1316906696OtherCOMMONWEALTH IND. - GIC
MAAA122242OtherHPHC