Healthcare Provider Details

I. General information

NPI: 1861021529
Provider Name (Legal Business Name): CLARE WYNNE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2020
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 GRAND CONCOURSE
BRONX NY
10457-7679
US

IV. Provider business mailing address

1276 FULTON AVE
BRONX NY
10456-3467
US

V. Phone/Fax

Practice location:
  • Phone: 718-992-7669
  • Fax:
Mailing address:
  • Phone: 718-992-7669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number324216
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: