Provider Demographics
NPI:1356338800
Name:WYCOFF, ROLLIN A (MD)
Entity type:Individual
Prefix:
First Name:ROLLIN
Middle Name:A
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:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:RATCLIFF
Mailing Address - State:AR
Mailing Address - Zip Code:72951
Mailing Address - Country:US
Mailing Address - Phone:479-431-2050
Mailing Address - Fax:479-431-2051
Practice Address - Street 1:708 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830
Practice Address - Country:US
Practice Address - Phone:479-668-3282
Practice Address - Fax:479-668-3284
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-3257207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146345001Medicaid
ARH22390Medicare UPIN
AR5M129Medicare ID - Type Unspecified