Healthcare Provider Details

I. General information

NPI: 1316023294
Provider Name (Legal Business Name): MARIA M. WISCOVITCH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARRETERA 194 CC21 FAJARDO GARDENS
FAJARDO PR
00738
US

IV. Provider business mailing address

PO BOX 362363
SAN JUAN PR
00936-2363
US

V. Phone/Fax

Practice location:
  • Phone: 787-655-7002
  • Fax: 787-655-7004
Mailing address:
  • Phone: 787-655-0505
  • Fax: 787-655-5059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number16301
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: