Provider Demographics
NPI:1396797817
Name:WYNNE, WALTER L (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:L
Last Name:WYNNE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:201 WILSHIRE BLVD
Mailing Address - Street 2:STE A26
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-1212
Mailing Address - Country:US
Mailing Address - Phone:310-874-0623
Mailing Address - Fax:
Practice Address - Street 1:2131 W 3RD ST
Practice Address - Street 2:ST VINCENT MEDICAL CENTER
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-1901
Practice Address - Country:US
Practice Address - Phone:310-874-0623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2010-05-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA043607208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA043607OtherSTATE LICENSE