Provider Demographics
NPI:1871584904
Name:WYATT, JOHN CREEDMORE III (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CREEDMORE
Last Name:WYATT
Suffix:III
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:PO BOX 180065
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-0065
Mailing Address - Country:US
Mailing Address - Phone:972-216-4411
Mailing Address - Fax:972-216-7346
Practice Address - Street 1:529 N GALLOWAY AVE
Practice Address - Street 2:SUITE 16
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-3420
Practice Address - Country:US
Practice Address - Phone:972-216-4411
Practice Address - Fax:972-216-7346
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE66952085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX88R743OtherBCBS
TX117996202Medicaid
TXB005OtherCHAMPUS
TXB005OtherCHAMPUS
TX88R743OtherBCBS