Healthcare Provider Details

I. General information

NPI: 1689646481
Provider Name (Legal Business Name): JAMES JEFFERSON WYSOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3103 CAMPBELL ST
SANDUSKY OH
44870
US

IV. Provider business mailing address

3103 CAMPBELL ST
SANDUSKY OH
44870
US

V. Phone/Fax

Practice location:
  • Phone: 419-625-4461
  • Fax: 419-625-5199
Mailing address:
  • Phone: 419-625-4461
  • Fax: 419-625-5199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35047619W
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: