Healthcare Provider Details

I. General information

NPI: 1538199443
Provider Name (Legal Business Name): WILLIE G. WYATT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: WILL G. WYATT M.D.

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5720 W MEMORIAL RD
OKLAHOMA CITY OK
73142-2010
US

IV. Provider business mailing address

5300 N INDEPENDENCE AVE STE 280
OKLAHOMA CITY OK
73112-5555
US

V. Phone/Fax

Practice location:
  • Phone: 405-470-7100
  • Fax: 405-470-7111
Mailing address:
  • Phone: 405-552-0155
  • Fax: 405-713-7690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9068
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: