Healthcare Provider Details

I. General information

NPI: 1285855148
Provider Name (Legal Business Name): DAVID J WYKSTRA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 PIONEER ST STE C
WAYCROSS GA
31501-6205
US

IV. Provider business mailing address

3437 DRIGGERS RD
WAYCROSS GA
31503-9512
US

V. Phone/Fax

Practice location:
  • Phone: 912-490-4805
  • Fax: 888-498-4449
Mailing address:
  • Phone: 912-281-2144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number055907
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: