Provider Demographics
NPI:1487646154
Name:BEDEAU, JOHN WYCLIFF (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WYCLIFF
Last Name:BEDEAU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9301 LARGO DR WEST SUITE 201
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-4884
Mailing Address - Country:US
Mailing Address - Phone:301-350-8722
Mailing Address - Fax:301-350-8822
Practice Address - Street 1:9301 LARGO DRIVE WEST SUITE 201
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-4884
Practice Address - Country:US
Practice Address - Phone:301-350-8722
Practice Address - Fax:301-350-8822
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0030666207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC025110100Medicaid
MD117681Medicare PIN
MDC61939Medicare UPIN