Provider Demographics
NPI:1083625388
Name:WYCOFF, DAVID RALPH
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:RALPH
Last Name:WYCOFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3922 S FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-3728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4812 E 33RD ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2038
Practice Address - Country:US
Practice Address - Phone:918-622-4126
Practice Address - Fax:918-270-2398
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1528225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
100834750AOtherMEDICAID LEGACY
243631709OtherMEDICARE LEGACY
892690007003OtherBCBS LEGACY
4581366OtherAETNA LEGACY
OK100834750AMedicaid
OK100834750AMedicaid