Provider Demographics
NPI:1992976039
Name:WILLIAM C. WYATT, O.D., P.A.
Entity type:Organization
Organization Name:WILLIAM C. WYATT, O.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:870-892-9169
Mailing Address - Street 1:204 N THOMASVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:POCAHONTAS
Mailing Address - State:AR
Mailing Address - Zip Code:72455-2665
Mailing Address - Country:US
Mailing Address - Phone:870-892-9169
Mailing Address - Fax:870-892-4031
Practice Address - Street 1:204 N THOMASVILLE AVE
Practice Address - Street 2:
Practice Address - City:POCAHONTAS
Practice Address - State:AR
Practice Address - Zip Code:72455-2665
Practice Address - Country:US
Practice Address - Phone:870-892-9169
Practice Address - Fax:870-892-4031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2210152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR48671Medicare PIN
AR0160140001Medicare NSC