Provider Demographics
NPI:1538173646
Name:WYATT, E. M. BRENDAN
Entity type:Individual
Prefix:
First Name:E. M. BRENDAN
Middle Name:
Last Name:WYATT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 OFFICE PARK CIR
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701-6538
Mailing Address - Country:US
Mailing Address - Phone:334-872-3403
Mailing Address - Fax:334-872-3405
Practice Address - Street 1:2 OFFICE PARK CIR
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-6538
Practice Address - Country:US
Practice Address - Phone:334-872-3403
Practice Address - Fax:334-872-3405
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME167191207W00000X
AL20641207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009976795Medicaid
AL051525773OtherBLUE CROSS BLUE SHIELD
AL051002044OtherBLUE CROSS BLUE SHIELD
AL000002044Medicaid