Healthcare Provider Details

I. General information

NPI: 1932360468
Provider Name (Legal Business Name): DAVID K. WYSONG DPM, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 07/02/2008
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 Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07000579A
License Number StateIN

VIII. Authorized Official

Name: DR. DAVID K WYSONG
Title or Position: PRESIDENT
Credential: DPM
Phone: 260-471-6830