MEDICARE: WILLIAM J. VAN WYK M.D., P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2500X	Medical Specialty Clinic/Center	D9696	TX

General Provider Information

NPI Number	:	1073781050
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLIAM J. VAN WYK M.D., P.A.

Provider Business Mailing Address
First Line	:	803 W TERRELL AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3155
Country	:	US
Telephone Number	:	817-877-3113
Fax Number	:	817-877-0022

Provider Business Practice Location Address
First Line	:	803 W TERRELL AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3155
Country	:	US
Telephone Number	:	817-877-3113
Fax Number	:	817-877-0022

Authorized Official
Title or Position	:	PRESIDENT
Name	:	WILLIAM J. VAN WYK
Credential	:	M.D., P.A.
Telephone Number	:	817-877-3113

Provider Enumeration Date	:	02/13/2008
Last Update Date	:	02/16/2011

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