Provider Demographics
NPI:1780621516
Name:WYCKOFF FAMILY MEDICAL SERVICES P C
Entity type:Organization
Organization Name:WYCKOFF FAMILY MEDICAL SERVICES P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:FARIDEH
Authorized Official - Middle Name:
Authorized Official - Last Name:ZONOUZI-ZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-963-6485
Mailing Address - Street 1:374 STOCKHOLM ST
Mailing Address - Street 2:C/O FACULTY PRACTICE MANAGEMENT- SUITE 1-37 N
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-4006
Mailing Address - Country:US
Mailing Address - Phone:718-963-6485
Mailing Address - Fax:718-963-6793
Practice Address - Street 1:374 STOCKHOLM ST
Practice Address - Street 2:C/O FACULTY PRACTICE MANAGEMENT- SUITE 1-37 N
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4006
Practice Address - Country:US
Practice Address - Phone:718-963-6485
Practice Address - Fax:718-963-6793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03313540Medicaid
NYWY8201Medicare PIN