Provider Demographics
NPI:1003312810
Name:WYCKOFF, SAMANTHA MEGAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:MEGAN
Last Name:WYCKOFF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:MEGAN
Other - Last Name:LABIB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:525 E 68TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-4870
Mailing Address - Country:US
Mailing Address - Phone:718-920-3185
Mailing Address - Fax:718-882-3185
Practice Address - Street 1:111 N 49TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-2718
Practice Address - Country:US
Practice Address - Phone:215-471-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306481-012084A0401X
390200000X
PAMD4803182084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program