Healthcare Provider Details

I. General information

NPI: 1720008931
Provider Name (Legal Business Name): TARA L. WYCHE-BULLOCK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 01/07/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 WILLIAMSTOWN RD
SICKLERVILLE NJ
08081-1777
US

IV. Provider business mailing address

155 BRIDGETON PIKE
MULLICA HILL NJ
08062-2669
US

V. Phone/Fax

Practice location:
  • Phone: 856-237-8100
  • Fax: 856-237-8042
Mailing address:
  • Phone: 856-223-0500
  • Fax: 856-223-1098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA07694800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: