Healthcare Provider Details

I. General information

NPI: 1881806446
Provider Name (Legal Business Name): JERICO ISIDERIO ALVARAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 06/14/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3727 W WISCONSIN AVE
MILWAUKEE WI
53208-3182
US

IV. Provider business mailing address

2054 S 102ND ST APT. 311B
WEST ALLIS WI
53227-1375
US

V. Phone/Fax

Practice location:
  • Phone: 414-291-2626
  • Fax:
Mailing address:
  • Phone: 262-365-3725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number50259
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT 184726
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number50259-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: