Provider Demographics
NPI:1962623389
Name:WYNN, LAURENCE (MD, MPH)
Entity type:Individual
Prefix:
First Name:LAURENCE
Middle Name:
Last Name:WYNN
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 WEDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MONTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07045-9044
Mailing Address - Country:US
Mailing Address - Phone:973-263-5336
Mailing Address - Fax:
Practice Address - Street 1:35 HACKENSACK AVE
Practice Address - Street 2:
Practice Address - City:KEARNY
Practice Address - State:NJ
Practice Address - Zip Code:07032-4635
Practice Address - Country:US
Practice Address - Phone:973-491-5525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA044635002083P0901X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice