Healthcare Provider Details

I. General information

NPI: 1053360420
Provider Name (Legal Business Name): WILLIAM HAYES WYTTENBACH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 06/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16329 S. TAMIAMI TRAIL
FORT MYERS FL
33908
US

IV. Provider business mailing address

16329 S. TAMIAMI TRAIL SUITE 5 & 6
FORT MYERS FL
33908
US

V. Phone/Fax

Practice location:
  • Phone: 239-949-7246
  • Fax: 239-949-7236
Mailing address:
  • Phone: 239-949-7246
  • Fax: 239-949-7236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberH9449
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number25415
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: