Provider Demographics
NPI:1720043433
Name:WYATT, DAVID J (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
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:PO BOX 975
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-0975
Mailing Address - Country:US
Mailing Address - Phone:225-658-9996
Mailing Address - Fax:225-658-9970
Practice Address - Street 1:4845 MAIN STREET
Practice Address - Street 2:SUITE B-1
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-5364
Practice Address - Country:US
Practice Address - Phone:225-658-9996
Practice Address - Fax:225-658-9970
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15788R207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1473472Medicaid
LA1473472Medicaid
LA5470870001Medicare NSC