Provider Demographics
NPI:1871563965
Name:WYATT, LARRY (DO)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:
Last Name:WYATT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 635
Mailing Address - Street 2:
Mailing Address - City:BELLMAWR
Mailing Address - State:NJ
Mailing Address - Zip Code:08099-0635
Mailing Address - Country:US
Mailing Address - Phone:856-770-5772
Mailing Address - Fax:856-566-2797
Practice Address - Street 1:2201 CHAPEL AVE W
Practice Address - Street 2:KENNEDY MEMORIAL HOSPITAL-UMC
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-2048
Practice Address - Country:US
Practice Address - Phone:856-488-6560
Practice Address - Fax:856-488-6546
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB032175207ZP0102X, 207ZC0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Not Answered207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3856909Medicaid
NJ3856909Medicaid
NJ594064ASSMedicare ID - Type Unspecified