1487611091 NPI number — DR. BOB K WYNN M.D.

Table of content: DR. BOB K WYNN M.D. (NPI 1487611091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487611091 NPI number — DR. BOB K WYNN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WYNN
Provider First Name:
BOB
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487611091
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1270
Provider Second Line Business Mailing Address:
296 US HWY BUSINESS 96
Provider Business Mailing Address City Name:
BUNA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77612-1270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-994-2427
Provider Business Mailing Address Fax Number:
409-994-3132

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
296 US HWY BUSINESS 96
Provider Second Line Business Practice Location Address:
POB 1270
Provider Business Practice Location Address City Name:
BUNA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77612-1270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-994-2427
Provider Business Practice Location Address Fax Number:
409-994-3132
Provider Enumeration Date:
04/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  F2723 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 112088301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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