Provider Demographics
NPI:1457314494
Name:WYCHE, RONALD C (MD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:C
Last Name:WYCHE
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 1:804 N BEECH ST
Mailing Address - Street 2:
Mailing Address - City:TALLULAH
Mailing Address - State:LA
Mailing Address - Zip Code:71282-3809
Mailing Address - Country:US
Mailing Address - Phone:318-574-1453
Mailing Address - Fax:318-574-5876
Practice Address - Street 1:804 N BEECH ST
Practice Address - Street 2:
Practice Address - City:TALLULAH
Practice Address - State:LA
Practice Address - Zip Code:71282-3809
Practice Address - Country:US
Practice Address - Phone:318-574-1453
Practice Address - Fax:318-574-5876
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012851207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1173045Medicaid
LAB60525Medicare UPIN
LA5J567Medicare ID - Type Unspecified