Healthcare Provider Details

I. General information

NPI: 1548369986
Provider Name (Legal Business Name): MARILYN A WYSOCKI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 GRAND CONCOURSE
BRONX NY
10457
US

IV. Provider business mailing address

210 MCADOO AVE
JERSEY CITY NJ
07305
US

V. Phone/Fax

Practice location:
  • Phone: 718-299-5000
  • Fax:
Mailing address:
  • Phone: 718-299-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number145601
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: