Provider Demographics
NPI:1245347194
Name:WYATT, MARK S (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:WYATT
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1700 HOSPITAL SOUTH DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-6810
Mailing Address - Country:US
Mailing Address - Phone:770-944-7818
Mailing Address - Fax:770-944-6402
Practice Address - Street 1:1700 HOSPITAL SOUTH DR
Practice Address - Street 2:SUITE 202
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6810
Practice Address - Country:US
Practice Address - Phone:770-944-7818
Practice Address - Fax:770-944-6402
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2015-06-26
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Provider Licenses
StateLicense IDTaxonomies
GA032499208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000414939CMedicaid
GA02BDCCBMedicare ID - Type Unspecified
GA000414939CMedicaid