Provider Demographics
NPI:1073537403
Name:WYN, TOD (MD)
Entity Type:Individual
Prefix:
First Name:TOD
Middle Name:
Last Name:WYN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 HOOVER BLVD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3719
Mailing Address - Country:US
Mailing Address - Phone:616-396-2972
Mailing Address - Fax:616-396-2808
Practice Address - Street 1:270 HOOVER BLVD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3719
Practice Address - Country:US
Practice Address - Phone:616-396-2972
Practice Address - Fax:616-396-2808
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060023207PE0004X, 207PH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MITW060023OtherBCBS
MI930017975OtherRAILROAD MEDICARE
MITW060023OtherBCBS
MI930017975OtherRAILROAD MEDICARE