Healthcare Provider Details

I. General information

NPI: 1134121577
Provider Name (Legal Business Name): RICHARD E WYSZYNSKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 06/02/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4676 DOUGLAS CIR NW
CANTON OH
44718-3619
US

IV. Provider business mailing address

4676 DOUGLAS CIR NW
CANTON OH
44718-3619
US

V. Phone/Fax

Practice location:
  • Phone: 330-494-1116
  • Fax: 330-494-0276
Mailing address:
  • Phone: 330-494-1116
  • Fax: 330-494-0276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number35-054663-W
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number35.054663
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: