Provider Demographics
NPI:1346283025
Name:WYATT, BRENT MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:MICHAEL
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 1:2619 SE MILITARY DR STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78223-4312
Mailing Address - Country:US
Mailing Address - Phone:210-704-1777
Mailing Address - Fax:
Practice Address - Street 1:910 S KIMBALL AVE
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-9005
Practice Address - Country:US
Practice Address - Phone:817-527-3470
Practice Address - Fax:817-527-3444
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0850X
TXM7769207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX189948601Medicaid
TX8AH272OtherBCBS
TX189948603Medicaid
TX189948601Medicaid
TX8L17005Medicare PIN
TX8AH272OtherBCBS