Provider Demographics
NPI:1316268774
Name:WYATT, MATTHEW MONROE (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MONROE
Last Name:WYATT
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:MAIL STOP 1034
Mailing Address - Street 2:3901 RAINBOW ROAD
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160
Mailing Address - Country:US
Mailing Address - Phone:913-588-6670
Mailing Address - Fax:
Practice Address - Street 1:251 E HURON ST
Practice Address - Street 2:GALTER 3-150
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2908
Practice Address - Country:US
Practice Address - Phone:312-926-8105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125058593207L00000X
KS04-37884207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology