Basic Information
Provider Information | |||||||||
NPI: | 1457594103 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WYSOCKI | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10 JOLLEY DR | ||||||||
Address2: | STE 102 | ||||||||
City: | BLOOMFIELD | ||||||||
State: | CT | ||||||||
PostalCode: | 060023061 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8602574131 | ||||||||
FaxNumber: | 8602574519 | ||||||||
Practice Location | |||||||||
Address1: | 2400 TAMARACK AVE | ||||||||
Address2: | SUITE 101 | ||||||||
City: | SOUTH WINDSOR | ||||||||
State: | CT | ||||||||
PostalCode: | 060745555 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8606444442 | ||||||||
FaxNumber: | 8606441412 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/10/2009 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/12/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 055947 | CT | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 7019762 | 01 | CT | CIGNA | OTHER | 4886159 | 01 | CT | AETNA | OTHER |