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General NPI Number Information
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NPI Number | 1154087013
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Entity Type | Organization
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Legal Business Name | DAVID WYKSTRA, MD, PC
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Dates
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Enumeration Date | 11/15/2021
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Last Update Date | 03/01/2022
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Provider Practice Location Address
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Address Line | 2005 PIONEER ST STE C
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City | WAYCROSS
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State | GA
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Zip | 31501-6205
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Country | US
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Telephone | 912-490-4805
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Fax |
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Provider Business Mailing Address
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Address Line | 3437 DRIGGERS RD
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City | WAYCROSS
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State | GA
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Zip | 31503-9512
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Country | US
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Telephone | 912-286-9192
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. DAVID WYKSTRA
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Credential | MD
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Telephone | 912-286-9192
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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