Provider Demographics
NPI:1346772928
Name:WYSOCKI, MATTHEW STEPHEN (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:STEPHEN
Last Name:WYSOCKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:9011 N MERIDIAN ST STE 225
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-5365
Mailing Address - Country:US
Mailing Address - Phone:317-574-4747
Mailing Address - Fax:
Practice Address - Street 1:8205 E 56TH ST STE 250
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46216-1097
Practice Address - Country:US
Practice Address - Phone:317-353-8985
Practice Address - Fax:317-353-2389
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-01
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02006835A207RN0300X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology