Healthcare Provider Details

I. General information

NPI: 1811073794
Provider Name (Legal Business Name): JAMES LAWRENCE WYNN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-0296
US

IV. Provider business mailing address

1600 SW ARCHER RD PO BOX 100296
GAINESVILLE FL
32610-0296
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-8985
  • Fax: 352-273-9054
Mailing address:
  • Phone: 352-273-8985
  • Fax: 352-273-9054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberME 123962
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: