Healthcare Provider Details

I. General information

NPI: 1326781220
Provider Name (Legal Business Name): WYATT BOOTHBY-SHOEMAKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HEALTH PARK DR STE 205
OWOSSO MI
48867-1291
US

IV. Provider business mailing address

200 HEALTH PARK DR STE 205
OWOSSO MI
48867-1291
US

V. Phone/Fax

Practice location:
  • Phone: 989-723-8666
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number1326781220
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: