Healthcare Provider Details

I. General information

NPI: 1053390856
Provider Name (Legal Business Name): JOSEPH S WOLYNIAK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7004 SMITH CORNERS BLVD SUITE A
CHARLOTTE NC
28269-3793
US

IV. Provider business mailing address

7004 SMITH CORNERS BLVD SUITE A
CHARLOTTE NC
28269-3793
US

V. Phone/Fax

Practice location:
  • Phone: 704-688-9650
  • Fax: 704-688-9651
Mailing address:
  • Phone: 704-688-9650
  • Fax: 704-688-9651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9600781
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number9600781
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: