Healthcare Provider Details

I. General information

NPI: 1316780299
Provider Name (Legal Business Name): WYATT MATTHEW LANDRITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 STANTON L YOUNG BLVD
OKLAHOMA CITY OK
73104-5020
US

IV. Provider business mailing address

5909 GRANDBY RD
EDMOND OK
73034-1700
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-2422
  • Fax: 405-271-2568
Mailing address:
  • Phone: 405-919-9983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number1099R
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: