Basic Information
| Provider Information | |||||||||
| NPI: | 1114050663 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WYSOLMERSKI | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 208020 | ||||||||
| Address2: | 789 HOWARD AVENUE | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065208020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037371058 | ||||||||
| FaxNumber: | 2037382812 | ||||||||
| Practice Location | |||||||||
| Address1: | 789 HOWARD AVE | ||||||||
| Address2: | DANA CLINIC BUILDING | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065208020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037371058 | ||||||||
| FaxNumber: | 2037372812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 01/28/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 030740 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 001307405 | 05 | CT | MEDICAID |