1538328810 NPI number — DR. JAMES STEVEN WYSOCK MD

Table of content: DR. JAMES STEVEN WYSOCK MD (NPI 1538328810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538328810 NPI number — DR. JAMES STEVEN WYSOCK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WYSOCK
Provider First Name:
JAMES
Provider Middle Name:
STEVEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538328810
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5645 MAIN ST
Provider Second Line Business Mailing Address:
W-LL300
Provider Business Mailing Address City Name:
FLUSHING
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11355-5045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-670-2127
Provider Business Mailing Address Fax Number:
718-961-1853

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5645 MAIN ST
Provider Second Line Business Practice Location Address:
W-LL300
Provider Business Practice Location Address City Name:
FLUSHING
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11355-5045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-445-0220
Provider Business Practice Location Address Fax Number:
718-939-1167
Provider Enumeration Date:
06/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  244348 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: '03382978 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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