Basic Information
| Provider Information | |||||||||
| NPI: | 1629347752 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WYCOCO | ||||||||
| FirstName: | ALVIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31464 POLO CREEK RD | ||||||||
| Address2: | |||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925917411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737573460 | ||||||||
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| Practice Location | |||||||||
| Address1: | 163 VAN BUREN RD | ||||||||
| Address2: | |||||||||
| City: | CARIBOU | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047363567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074983111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME114576 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | Q2633 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | MD20530 | ME | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.