Basic Information
Provider Information | |||||||||
NPI: | 1891730685 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WYKO | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | B | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2995 DREW ST FL 2 | ||||||||
Address2: |   | ||||||||
City: | CLEARWATER | ||||||||
State: | FL | ||||||||
PostalCode: | 337593012 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7275321355 | ||||||||
FaxNumber: | 8136352613 | ||||||||
Practice Location | |||||||||
Address1: | 180 PATRICIA AVE | ||||||||
Address2: |   | ||||||||
City: | DUNEDIN | ||||||||
State: | FL | ||||||||
PostalCode: | 346988103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7277334193 | ||||||||
FaxNumber: | 8136352628 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2006 | ||||||||
LastUpdateDate: | 03/22/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | OS3673 | FL | Y |   | Allopathic & Osteopathic Physicians | General Practice |   |
ID Information
ID | Type | State | Issuer | Description | 0105064 | 01 | FL | UNITED HEALTHCARE | OTHER | 1679215 | 01 | FL | CIGNA | OTHER | 123317 | 01 | FL | HUMANA | OTHER | 593709395 | 01 | FL | TAX ID | OTHER | 010065622 | 01 | FL | RAILROAD MEDICARE | OTHER | 021226000 | 05 | FL |   | MEDICAID | 0100584 | 01 | FL | EVERCARE | OTHER | 211531 | 01 | FL | AVMED | OTHER | 5352090 | 01 | FL | AETNA | OTHER | 82091 | 01 | FL | BCBS | OTHER |