Healthcare Provider Details

I. General information

NPI: 1346772928
Provider Name (Legal Business Name): MATTHEW STEPHEN WYSOCKI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2017
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8205 E 56TH ST STE 250
INDIANAPOLIS IN
46216-1097
US

IV. Provider business mailing address

9011 N MERIDIAN ST STE 225
INDIANAPOLIS IN
46260-5365
US

V. Phone/Fax

Practice location:
  • Phone: 317-353-8985
  • Fax: 317-353-2389
Mailing address:
  • Phone: 317-574-4747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number02006835A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: