MEDICARE: DOUGLAS B WYATT M.D.

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	208600000X	Surgery Physician	G9018	TX
2	2086S0129X	Vascular Surgery Physician	G9018	TX

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
2	00N46H	OTHER	TX	BCBS OF TEXAS

General Provider Information

NPI Number	:	1801809439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS B WYATT M.D.

Provider Business Mailing Address
First Line	:	3501 S SONCY RD STE 109
Second Line	:
City	:	AMARILLO
State	:	TX
Zip	:	79119-6405
Country	:	US
Telephone Number	:	806-467-2888
Fax Number	:	806-467-2999

Provider Business Practice Location Address
First Line	:	3501 S SONCY RD STE 109
Second Line	:
City	:	AMARILLO
State	:	TX
Zip	:	79119-6405
Country	:	US
Telephone Number	:	806-467-2888
Fax Number	:	806-467-2999

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

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	05/31/2011

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Directions to “ DOUGLAS B WYATT M.D.” Practice Location

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