MEDICARE: DR. KIMBERLY SUE WYATT MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	ME121614	FL
2	207RG0100X	Gastroenterology Physician	ME121614	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	IBWUZ	OTHER	FL	FLORIDA BLUE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326024902
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIMBERLY SUE WYATT MD

Provider Business Mailing Address
First Line	:	PO BOX 417
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34995-0417
Country	:	US
Telephone Number	:	772-223-2832
Fax Number	:	772-223-5665

Provider Business Practice Location Address
First Line	:	509 SE RIVERSIDE DR STE 303
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34994-2579
Country	:	US
Telephone Number	:	772-283-9111
Fax Number	:	772-781-2785

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2005
Last Update Date	:	10/13/2020

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