Provider Demographics
NPI:1629508965
Name:VERPLAETSE, WYATT ANDREW (MD)
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:ANDREW
Last Name:VERPLAETSE
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 1:1001 MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-2035
Mailing Address - Country:US
Mailing Address - Phone:309-308-2010
Mailing Address - Fax:309-671-2167
Practice Address - Street 1:1001 MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-2035
Practice Address - Country:US
Practice Address - Phone:309-308-2010
Practice Address - Fax:309-671-2167
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-19
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036155926207R00000X
MO2022026074207K00000X
IL125.071367208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics