Provider Demographics
NPI:1598781643
Name:WYZAN, DANIEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:S
Last Name:WYZAN
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 1:425 NORTH LEE ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-1128
Mailing Address - Country:US
Mailing Address - Phone:904-354-8200
Mailing Address - Fax:904-354-1340
Practice Address - Street 1:425 NORTH LEE ST
Practice Address - Street 2:SUITE 203
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-1128
Practice Address - Country:US
Practice Address - Phone:904-354-8200
Practice Address - Fax:904-354-1340
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48699207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00453747AOtherMEDICAID OF GEORGIA
FL07238ZOtherBCBS OF FLORIDA
FL051258300Medicaid
FL2540584OtherAETNA
FL07238ZMedicare PIN
FL07238ZOtherBCBS OF FLORIDA
FLD61482Medicare UPIN