Healthcare Provider Details

I. General information

NPI: 1891722120
Provider Name (Legal Business Name): PATRICK WOLCOTT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 04/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 W ORANGE AVE SUITE D
EL CENTRO CA
92243
US

IV. Provider business mailing address

516 W ATEN RD STE 2
IMPERIAL CA
92251-9805
US

V. Phone/Fax

Practice location:
  • Phone: 760-353-8858
  • Fax: 760-545-0248
Mailing address:
  • Phone: 760-355-7730
  • Fax: 760-355-7731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG55463
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: