MEDICARE: CHARLES BRADFORD WYSONG MD

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	2085R0202X	Diagnostic Radiology Physician	E1192	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437113222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES BRADFORD WYSONG MD

Provider Business Mailing Address
First Line	:	PO BOX 740968
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75374-0968
Country	:	US
Telephone Number	:	800-945-2455
Fax Number	:	903-453-2541

Provider Business Practice Location Address
First Line	:	130 S CENTRAL EXPY
Second Line	:	WEST PARK MEDICAL CENTER
City	:	MCKINNEY
State	:	TX
Zip	:	75070-3742
Country	:	US
Telephone Number	:	972-548-5308
Fax Number	:	972-548-5433

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2006
Last Update Date	:	07/30/2009

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