Healthcare Provider Details

I. General information

NPI: 1083926919
Provider Name (Legal Business Name): THEODORE EUGENE WYMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3579 ARLINGTON AVE STE 300
RIVERSIDE CA
92506-3915
US

IV. Provider business mailing address

3579 ARLINGTON AVE STE 300
RIVERSIDE CA
92506-3915
US

V. Phone/Fax

Practice location:
  • Phone: 951-341-9333
  • Fax: 951-341-9330
Mailing address:
  • Phone: 951-341-9333
  • Fax: 951-341-9330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberA104884
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA104884
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: