Provider Demographics
NPI:1053360420
Name:WYTTENBACH, WILLIAM HAYES (MD)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:HAYES
Last Name:WYTTENBACH
Suffix:
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 1:16329 S. TAMIAMI TRAIL
Mailing Address - Street 2:SUITE 5 & 6
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908
Mailing Address - Country:US
Mailing Address - Phone:239-949-7246
Mailing Address - Fax:239-949-7236
Practice Address - Street 1:16329 S. TAMIAMI TRAIL
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908
Practice Address - Country:US
Practice Address - Phone:239-949-7246
Practice Address - Fax:239-949-7236
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9449207L00000X
KY25415207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX030084003Medicaid
TX098671304Medicaid
TX030084003Medicaid
TXC36318Medicare UPIN
TX030084003Medicare PIN