MEDICARE: DECATUR DERMATOLOGY, PC

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	207NS0135X	Procedural Dermatology Physician
2	207N00000X	Dermatology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770782849
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DECATUR DERMATOLOGY, PC

Provider Business Mailing Address
First Line	:	620 WALNUT STREET NE
Second Line	:	SUITE A
City	:	DECATUR
State	:	AL
Zip	:	35601-2456
Country	:	US
Telephone Number	:	256-353-7775
Fax Number	:	256-353-7765

Provider Business Practice Location Address
First Line	:	620 WALNUT STREET NE
Second Line	:	SUITE A
City	:	DECATUR
State	:	AL
Zip	:	35601-2456
Country	:	US
Telephone Number	:	256-353-7775
Fax Number	:	256-353-7765

Authorized Official
Title or Position	:	PHYSICIAN/PRESIDENT
Name	:	SAMANTHA WYATT
Credential	:	MD
Telephone Number	:	256-353-7775

Provider Enumeration Date	:	07/17/2007
Last Update Date	:	08/21/2025

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