Provider Demographics
NPI:1386654499
Name:WYSE, CAROL YVONNE (DO)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:YVONNE
Last Name:WYSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:Y
Other - Last Name:SWARTZENTRUBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 320945
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532
Mailing Address - Country:US
Mailing Address - Phone:810-655-5900
Mailing Address - Fax:810-655-5915
Practice Address - Street 1:6012 LINDEN RD
Practice Address - Street 2:SUITE 14
Practice Address - City:SWARTZ CREEK
Practice Address - State:MI
Practice Address - Zip Code:48473-8890
Practice Address - Country:US
Practice Address - Phone:810-655-5900
Practice Address - Fax:810-655-5915
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICW007869207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4079297Medicaid
080139268OtherRR MEDICARE
MI5250325OtherBCBSM
MI4079297Medicaid
MIP38520001Medicare PIN