Individual
DR. KENNY J WYATT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
202 PEABODY, MOUNTAIN VIEW, AR 72560
(870) 269-3610
(870) 269-5086
Mailing address
PO BOX 1460, MOUNTAIN VIEW, AR 72560-1460
(870) 269-3610
(870) 269-5086
Taxonomy
Speciality
Code
Description
License number
State
152WC0802X
Corneal and Contact Management Optometrist
Primary
2209
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
106031722
—
AR
01
—
16064000040
QUALCHOICE ID #
AR
01
—
P00135331
MEDICARE RR ID #
AR
Enumeration date
07/08/2005
Last updated
04/21/2010
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