Provider Demographics
NPI:1235373150
Name:BRAD WYSONG MD PA
Entity Type:Organization
Organization Name:BRAD WYSONG MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:B
Authorized Official - Last Name:WYSONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-548-5308
Mailing Address - Street 1:PO BOX 740968
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75374-0968
Mailing Address - Country:US
Mailing Address - Phone:800-945-2455
Mailing Address - Fax:469-742-0771
Practice Address - Street 1:130 S CENTRAL EXPY
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070-3742
Practice Address - Country:US
Practice Address - Phone:972-548-5308
Practice Address - Fax:972-548-5433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-22
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A3840Medicare PIN