Provider Demographics
NPI:1871561126
Name:WYATT, JOSEPH O (MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:O
Last Name:WYATT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:WYATT
Other - Middle Name:JOE
Other - Last Name:WOLLMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:100 MAC LANE
Mailing Address - Street 2:AVERA MEDICAL GROUP PIERRE
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501
Mailing Address - Country:US
Mailing Address - Phone:605-945-5259
Mailing Address - Fax:605-945-5094
Practice Address - Street 1:100 MAC LANE
Practice Address - Street 2:AVERA MEDICAL GROUP PIERRE
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501
Practice Address - Country:US
Practice Address - Phone:605-945-5259
Practice Address - Fax:605-945-5094
Is Sole Proprietor?:No
Enumeration Date:2006-03-12
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL025520208800000X
SD7274208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7500522Medicaid
SD7500522Medicaid