Provider Demographics
NPI:1427056951
Name:WYATT, KENNY J (OD)
Entity type:Individual
Prefix:DR
First Name:KENNY
Middle Name:J
Last Name:WYATT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1460
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:AR
Mailing Address - Zip Code:72560-1460
Mailing Address - Country:US
Mailing Address - Phone:870-269-3610
Mailing Address - Fax:870-269-5086
Practice Address - Street 1:202 PEABODY
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:AR
Practice Address - Zip Code:72560
Practice Address - Country:US
Practice Address - Phone:870-269-3610
Practice Address - Fax:870-269-5086
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2209152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR16064000040OtherQUALCHOICE ID #
AR106031722Medicaid
ARP00135331OtherMEDICARE RR ID #
ARP00135331OtherMEDICARE RR ID #
AR16064000040OtherQUALCHOICE ID #