Provider Demographics
NPI:1487793618
Name:WYTIAZ, GARY JAMES (DC)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:JAMES
Last Name:WYTIAZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 GLENN CARRIE RD
Mailing Address - Street 2:
Mailing Address - City:HULL
Mailing Address - State:GA
Mailing Address - Zip Code:30646-4203
Mailing Address - Country:US
Mailing Address - Phone:706-548-1419
Mailing Address - Fax:
Practice Address - Street 1:164 GLENN CARRIE RD
Practice Address - Street 2:
Practice Address - City:HULL
Practice Address - State:GA
Practice Address - Zip Code:30646-4203
Practice Address - Country:US
Practice Address - Phone:706-548-1419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001972111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation