Healthcare Provider Details

I. General information

NPI: 1477846236
Provider Name (Legal Business Name): EDWARD J WYLUDA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5008 BRITTONFIELD PKWY STE 700
EAST SYRACUSE NY
13057
US

IV. Provider business mailing address

5008 BRITTONFIELD PKWY STE 700
EAST SYRACUSE NY
13057-9249
US

V. Phone/Fax

Practice location:
  • Phone: 315-472-7504
  • Fax: 315-634-4677
Mailing address:
  • Phone: 315-472-7504
  • Fax: 315-634-4677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOT014151
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number289014
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: