Provider Demographics
NPI:1285855148
Name:WYKSTRA, DAVID J (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:WYKSTRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
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:912-281-2144
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:888-498-4449
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055907208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA655012398BMedicaid
GA02BDJLWMedicare PIN