Basic Information
| Provider Information | |||||||||
| NPI: | 1841853173 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYZGOSKI | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GITTLEMAN | ||||||||
| OtherFirstName: | DANIELLE | ||||||||
| OtherMiddleName: | ERIN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 412 E SUNNYBROOK DR | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480732635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483206291 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14500 HALL RD | ||||||||
| Address2: | |||||||||
| City: | STERLING HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483131229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862472700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2019 | ||||||||
| LastUpdateDate: | 06/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | 5101026731 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 5101026731 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.