Healthcare Provider Details

I. General information

NPI: 1689832354
Provider Name (Legal Business Name): WYCLIFFE OKUMU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 HOSPITAL DR
MONROE NC
28112-6000
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-993-2240
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2011-01354
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number53462-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: