Healthcare Provider Details

I. General information

NPI: 1609961523
Provider Name (Legal Business Name): ROBERT RALPH WYSOKINSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 12/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 WEST BROAD ST
COLUMBUS OH
43222
US

IV. Provider business mailing address

1744 MORELAND DRIVE
COLUMBUS OH
43220
US

V. Phone/Fax

Practice location:
  • Phone: 614-272-0509
  • Fax:
Mailing address:
  • Phone: 614-459-9543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number56830
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: