Basic Information
| Provider Information | |||||||||
| NPI: | 1356338800 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYCOFF | ||||||||
| FirstName: | ROLLIN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 130 | ||||||||
| Address2: | |||||||||
| City: | RATCLIFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794312050 | ||||||||
| FaxNumber: | 4794312051 | ||||||||
| Practice Location | |||||||||
| Address1: | 708 WEST MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796683282 | ||||||||
| FaxNumber: | 4796683284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 07/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E-3257 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 146345001 | 05 | AR | MEDICAID |