Provider Demographics
NPI:1740384304
Name:WYCOFF, RUSSELL ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:ROBERT
Last Name:WYCOFF
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 1:751 CORDOVA STREET
Mailing Address - Street 2:SUITE #1
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2617
Mailing Address - Country:US
Mailing Address - Phone:626-577-2424
Mailing Address - Fax:626-577-2995
Practice Address - Street 1:751 CORDOVA STREET
Practice Address - Street 2:SUITE #1
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2617
Practice Address - Country:US
Practice Address - Phone:626-577-2424
Practice Address - Fax:626-577-2995
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG167502085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Not Answered2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A39894Medicare UPIN