1114050663 NPI number — JOHN J WYSOLMERSKI MD

Table of content: JOHN J WYSOLMERSKI MD (NPI 1114050663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114050663 NPI number — JOHN J WYSOLMERSKI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WYSOLMERSKI
Provider First Name:
JOHN
Provider Middle Name:
J
Provider Name Prefix Text:
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:
1114050663
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 208020
Provider Second Line Business Mailing Address:
789 HOWARD AVENUE
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06520-8020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-737-1058
Provider Business Mailing Address Fax Number:
203-738-2812

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
789 HOWARD AVE
Provider Second Line Business Practice Location Address:
DANA CLINIC BUILDING
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06520-8020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-737-1058
Provider Business Practice Location Address Fax Number:
203-737-2812
Provider Enumeration Date:
03/13/2007

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: 207RE0101X , with the licence number:  030740 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001307405 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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