Healthcare Provider Details

I. General information

NPI: 1528313624
Provider Name (Legal Business Name): ALVIN RAY WYATT II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10666 N TORREY PINES RD # 100C
LA JOLLA CA
92037-1027
US

IV. Provider business mailing address

PO BOX 232410
SAN DIEGO CA
92193-2410
US

V. Phone/Fax

Practice location:
  • Phone: 858-554-2626
  • Fax:
Mailing address:
  • Phone: 858-249-6748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number147190
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: