Provider Demographics
NPI:1548261902
Name:WYSZKOWSKI, RAFAL J (MD)
Entity type:Individual
Prefix:DR
First Name:RAFAL
Middle Name:J
Last Name:WYSZKOWSKI
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 6666
Mailing Address - Street 2:
Mailing Address - City:ST THOMAS
Mailing Address - State:VI
Mailing Address - Zip Code:00804-6666
Mailing Address - Country:US
Mailing Address - Phone:215-820-3219
Mailing Address - Fax:
Practice Address - Street 1:750 E ADAMS ST STE 4702
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2306
Practice Address - Country:US
Practice Address - Phone:315-464-4720
Practice Address - Fax:315-464-4905
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2019-08-15
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
PAMD061022L207LP2900X
NY197745207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF99101Medicare UPIN
752760Medicare ID - Type Unspecified