Provider Demographics
NPI:1992061436
Name:WYNN, BOB (MD)
Entity type:Individual
Prefix:
First Name:BOB
Middle Name:
Last Name:WYNN
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 1:5420 DASHWOOD DR STE 100
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77081-5333
Mailing Address - Country:US
Mailing Address - Phone:832-548-5000
Mailing Address - Fax:
Practice Address - Street 1:5420 DASHWOOD DR STE 100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77081-5333
Practice Address - Country:US
Practice Address - Phone:832-548-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD607399322084P0804X
ORMD1823792084P0804X
TXU96962084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry