Healthcare Provider Details

I. General information

NPI: 1346283025
Provider Name (Legal Business Name): BRENT MICHAEL WYATT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 03/05/2020
Certification Date: 03/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 S KIMBALL AVE
SOUTHLAKE TX
76092-9005
US

IV. Provider business mailing address

2619 SE MILITARY DR STE 101
SAN ANTONIO TX
78223-4312
US

V. Phone/Fax

Practice location:
  • Phone: 817-527-3470
  • Fax: 817-527-3444
Mailing address:
  • Phone: 210-704-1777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberM7769
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: