Provider Demographics
NPI:1588903959
Name:WYDEN, JOHN W C II
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:W C
Last Name:WYDEN
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 N HIGH ST
Mailing Address - Street 2:
Mailing Address - City:ANTLERS
Mailing Address - State:OK
Mailing Address - Zip Code:74523-2250
Mailing Address - Country:US
Mailing Address - Phone:580-298-3001
Mailing Address - Fax:580-298-5357
Practice Address - Street 1:112 N HIGH ST
Practice Address - Street 2:
Practice Address - City:ANTLERS
Practice Address - State:OK
Practice Address - Zip Code:74523-2250
Practice Address - Country:US
Practice Address - Phone:580-298-3001
Practice Address - Fax:580-298-5357
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional