Provider Demographics
NPI:1114050663
Name:WYSOLMERSKI, JOHN J (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:WYSOLMERSKI
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 208020
Mailing Address - Street 2:789 HOWARD AVENUE
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06520-8020
Mailing Address - Country:US
Mailing Address - Phone:203-737-1058
Mailing Address - Fax:203-738-2812
Practice Address - Street 1:789 HOWARD AVE
Practice Address - Street 2:DANA CLINIC BUILDING
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06520-8020
Practice Address - Country:US
Practice Address - Phone:203-737-1058
Practice Address - Fax:203-737-2812
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT030740207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001307405Medicaid
CT110004793Medicare ID - Type Unspecified
CT001307405Medicaid