Healthcare Provider Details

I. General information

NPI: 1629347752
Provider Name (Legal Business Name): ALVIN WYCOCO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 VAN BUREN RD
CARIBOU ME
04736-3567
US

IV. Provider business mailing address

31464 POLO CREEK RD
TEMECULA CA
92591-7411
US

V. Phone/Fax

Practice location:
  • Phone: 207-498-3111
  • Fax:
Mailing address:
  • Phone: 973-757-3460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME114576
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberQ2633
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD20530
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: