Provider Demographics
NPI:1902987555
Name:WYBENGA, MAARTEN ADRIAAN J (MD)
Entity type:Individual
Prefix:DR
First Name:MAARTEN
Middle Name:ADRIAAN J
Last Name:WYBENGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARTIN
Other - Middle Name:ADRIAAN J
Other - Last Name:WYBENGA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1321 NORTH COUNTY HIGHWAY 395
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459
Mailing Address - Country:US
Mailing Address - Phone:850-213-1133
Mailing Address - Fax:850-213-2533
Practice Address - Street 1:1321 NORTH COUNTY HIGHWAY 395
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459
Practice Address - Country:US
Practice Address - Phone:850-213-1133
Practice Address - Fax:850-213-2533
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13662207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051515040Medicaid
AL51515040OtherBLUE CROSS