Healthcare Provider Details

I. General information

NPI: 1083792378
Provider Name (Legal Business Name): WYCKOFF FAMILY MEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 ALEX CIR
STATEN ISLAND NY
10305-4765
US

IV. Provider business mailing address

374 STOCKHOLM ST
BROOKLYN NY
11237-4006
US

V. Phone/Fax

Practice location:
  • Phone: 917-744-0378
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number223830
License Number StateNY

VIII. Authorized Official

Name: JOANNE CAMPBELL
Title or Position: MANAGER
Credential:
Phone: 718-963-7272