Provider Demographics
NPI:1689646481
Name:WYSOR, JAMES JEFFERSON (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:JEFFERSON
Last Name:WYSOR
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 1:3103 CAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870
Mailing Address - Country:US
Mailing Address - Phone:419-625-4461
Mailing Address - Fax:419-625-5199
Practice Address - Street 1:3103 CAMPBELL ST
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870
Practice Address - Country:US
Practice Address - Phone:419-625-4461
Practice Address - Fax:419-625-5199
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35047619W207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH04375OtherPARAMOUNT
OH0538681Medicaid
OH000000131843OtherANTHEM
OH0538681Medicaid
OH04375OtherPARAMOUNT