Provider Demographics
NPI:1790164317
Name:WYCKOFF DOCTORS
Entity Type:Organization
Organization Name:WYCKOFF DOCTORS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:VUTRANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-963-6702
Mailing Address - Street 1:374 STOCKHOLM STREET
Mailing Address - Street 2:WYCKOFF PROFESSIONAL MEDICAL SERVICES, PC - FACULTY PRA
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-4006
Mailing Address - Country:US
Mailing Address - Phone:718-963-7676
Mailing Address - Fax:718-963-6667
Practice Address - Street 1:1610 DEKALB AVENUE
Practice Address - Street 2:WYCKOFF DOCTORS
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-3906
Practice Address - Country:US
Practice Address - Phone:718-963-7676
Practice Address - Fax:718-963-6667
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WYCKOFF PROFESSIONAL MEDICAL SERVICES PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-28
Last Update Date:2016-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03722025Medicaid
NY03722025Medicaid