Provider Demographics
NPI:1437113222
Name:WYSONG, CHARLES BRADFORD (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BRADFORD
Last Name:WYSONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:903-453-2541
Practice Address - Street 1:130 S CENTRAL EXPY
Practice Address - Street 2:WEST PARK MEDICAL CENTER
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE11922085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126284203Medicaid
TX126284203Medicaid
TX8F21389Medicare PIN
TX300009269Medicare PIN