Provider Demographics
NPI:1902987555
Name:WYBENGA, MAARTEN A (MD)
Entity Type:Individual
Prefix:DR
First Name:MAARTEN
Middle Name:A
Last Name:WYBENGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 BROWN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-7005
Mailing Address - Country:US
Mailing Address - Phone:334-747-4159
Mailing Address - Fax:
Practice Address - Street 1:645 MCQUEEN SMITH RD N STE 309
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36066-7269
Practice Address - Country:US
Practice Address - Phone:334-358-2010
Practice Address - Fax:334-358-2013
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13662207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51515040OtherBLUE CROSS
AL051515040Medicaid