Provider Demographics
NPI:1609214766
Name:WYCKSTANDT, JOSHUA D (MD)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:D
Last Name:WYCKSTANDT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:103 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-4703
Mailing Address - Country:US
Mailing Address - Phone:865-273-1752
Mailing Address - Fax:865-273-1755
Practice Address - Street 1:907 E LAMAR ALEXANDER PKWY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5015
Practice Address - Country:US
Practice Address - Phone:865-980-4897
Practice Address - Fax:865-977-4793
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN60327207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine