Healthcare Provider Details

I. General information

NPI: 1114050663
Provider Name (Legal Business Name): JOHN J WYSOLMERSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 01/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

789 HOWARD AVE DANA CLINIC BUILDING
NEW HAVEN CT
06520-8020
US

IV. Provider business mailing address

PO BOX 208020 789 HOWARD AVENUE
NEW HAVEN CT
06520-8020
US

V. Phone/Fax

Practice location:
  • Phone: 203-737-1058
  • Fax: 203-737-2812
Mailing address:
  • Phone: 203-737-1058
  • Fax: 203-738-2812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number030740
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: