Healthcare Provider Details

I. General information

NPI: 1386185627
Provider Name (Legal Business Name): COREY W WYNN MD, MED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SEYMOUR ST
HARTFORD CT
06106-5501
US

IV. Provider business mailing address

85 SEYMOUR ST STE 500
HARTFORD CT
06106-5524
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-9440
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number74368
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: