Healthcare Provider Details

I. General information

NPI: 1235373150
Provider Name (Legal Business Name): BRAD WYSONG MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2009
Last Update Date: 07/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 S CENTRAL EXPY
MCKINNEY TX
75070-3742
US

IV. Provider business mailing address

PO BOX 740968
DALLAS TX
75374-0968
US

V. Phone/Fax

Practice location:
  • Phone: 972-548-5308
  • Fax: 972-548-5433
Mailing address:
  • Phone: 800-945-2455
  • Fax: 469-742-0771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES B WYSONG
Title or Position: MD
Credential: MD
Phone: 972-548-5308