Healthcare Provider Details

I. General information

NPI: 1114956844
Provider Name (Legal Business Name): DAVID K WYSONG DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3012 E STATE BLVD
FORT WAYNE IN
46805-4737
US

IV. Provider business mailing address

3012 E STATE BLVD
FORT WAYNE IN
46805-4737
US

V. Phone/Fax

Practice location:
  • Phone: 260-471-6830
  • Fax: 260-471-6704
Mailing address:
  • Phone: 260-471-6830
  • Fax: 260-471-6704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07000579
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: