Healthcare Provider Details

I. General information

NPI: 1639651870
Provider Name (Legal Business Name): MARC A WYCKOFF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4780 N ORANGE BLOSSOM TRL
ORLANDO FL
32810
US

IV. Provider business mailing address

4780 N ORANGE BLOSSOM TRL
ORLANDO FL
32810-1601
US

V. Phone/Fax

Practice location:
  • Phone: 407-206-3326
  • Fax: 407-206-3316
Mailing address:
  • Phone: 407-206-3326
  • Fax: 407-206-3316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1311413
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070008229
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT34018
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: