Provider Demographics
NPI:1457594103
Name:WYSOCKI, JOHN D (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:D
Last Name:WYSOCKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:10 JOLLEY DR
Mailing Address - Street 2:STE 102
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-3061
Mailing Address - Country:US
Mailing Address - Phone:860-257-4131
Mailing Address - Fax:860-257-4519
Practice Address - Street 1:2400 TAMARACK AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-5555
Practice Address - Country:US
Practice Address - Phone:860-644-4442
Practice Address - Fax:860-644-1412
Is Sole Proprietor?:No
Enumeration Date:2009-04-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT055947207RG0100X
MA261640207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT7019762OtherCIGNA
CT4886159OtherAETNA
CTD400351760Medicare PIN