Basic Information
| Provider Information | |||||||||
| NPI: | 1487619961 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WYCOFF | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | O | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 E MICHIGAN AVE | ||||||||
| Address2: | SUITE 325 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489121800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173645160 | ||||||||
| FaxNumber: | 5173645165 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 E MICHIGAN AVE | ||||||||
| Address2: | SUITE 325 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489121800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173645160 | ||||||||
| FaxNumber: | 5173645165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101009308 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3477253 | 05 | MI | MEDICAID | 0853310114 | 01 | MI | BCBS PIN NUMBER | OTHER |