Individual
DR. BRENT MICHAEL WYATT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
910 S KIMBALL AVE, SOUTHLAKE, TX 76092-9005
(817) 527-3470
(817) 527-3444
Mailing address
2619 SE MILITARY DR STE 101, SAN ANTONIO, TX 78223-4312
(210) 704-1777
Taxonomy
Speciality
Code
Description
License number
State
207PE0004X
Emergency Medical Services (Emergency Medicine) Physician
Primary
M7769
TX
261QM0850X
Adult Mental Health Clinic/Center
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
189948601
—
TX
05
—
189948603
—
TX
01
—
8AH272
BCBS
TX
Enumeration date
06/13/2006
Last updated
03/05/2020
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