MEDICARE: J ROBERT WYATT MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	J8423	TX

General Provider Information

NPI Number	:	1619963808
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	J ROBERT WYATT MD

Provider Business Mailing Address
First Line	:	11970 N CENTRAL EXPY
Second Line	:	SUITE 400
City	:	DALLAS
State	:	TX
Zip	:	75243-3768
Country	:	US
Telephone Number	:	214-382-5100
Fax Number	:	214-382-5199

Provider Business Practice Location Address
First Line	:	11970 N CENTRAL EXPY
Second Line	:	SUITE 400
City	:	DALLAS
State	:	TX
Zip	:	75243-3768
Country	:	US
Telephone Number	:	214-382-5100
Fax Number	:	214-382-5199

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2005
Last Update Date	:	07/21/2014

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