Provider Demographics
NPI:1154087013
Name:DAVID WYKSTRA, MD, PC
Entity Type:Organization
Organization Name:DAVID WYKSTRA, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WYKSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-286-9192
Mailing Address - Street 1:3437 DRIGGERS RD
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31503-9512
Mailing Address - Country:US
Mailing Address - Phone:912-286-9192
Mailing Address - Fax:
Practice Address - Street 1:2005 PIONEER ST STE C
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-6205
Practice Address - Country:US
Practice Address - Phone:912-490-4805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-15
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty