Individual
JOHN CREEDMORE WYATT III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
529 N GALLOWAY AVE, SUITE 16, MESQUITE, TX 75149-3420
(972) 216-4411
(972) 216-7346
Mailing address
PO BOX 180065, DALLAS, TX 75218-0065
(972) 216-4411
(972) 216-7346
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
E6695
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
117996202
—
TX
01
—
88R743
BCBS
TX
01
—
B005
CHAMPUS
TX
Enumeration date
10/28/2005
Last updated
09/22/2008
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