Doctor Name: | DR. THEODORE EUGENE WYMAN |
NPI Number: | 1083926919 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | M.D. |
License Number: | A104884 |
Business Practice Address: | 264 N Highland Springs Ave Suite 5a Banning, CA - 922203082 |
Business Phone Number: | 9517690079 |
Business Fax Number: | |
Mailing Address: | 264 N Highland Springs Ave, Suite 5a BANNING |
State: | CA |
Postal Code: | 922203082 |
Phone Number: | 9517690079 |
Fax Number: | |
NPI Enumeration Date: | 07/08/2010 |
NPI Last Update Date: | 04/13/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 208D00000X |
License Number: | A104884 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | CA |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | General Practice |
Taxonomy Specialization: | |
Taxonomy Definition: |