Provider Demographics
NPI:1104816784
Name:WYKOFF, LORI A (MD)
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:A
Last Name:WYKOFF
Suffix:
Gender:F
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 809
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46527-0809
Mailing Address - Country:US
Mailing Address - Phone:574-533-1234
Mailing Address - Fax:574-537-2652
Practice Address - Street 1:415 E MADISON ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617
Practice Address - Country:US
Practice Address - Phone:574-533-1234
Practice Address - Fax:574-537-2652
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043680A208000000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200078780Medicaid
IN200078780Medicaid
IN146470FFMedicare ID - Type Unspecified