Basic Information
| Provider Information | |||||||||
| NPI: | 1891722120 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLCOTT | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 516 W ATEN RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | IMPERIAL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922519805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603557730 | ||||||||
| FaxNumber: | 7603557731 | ||||||||
| Practice Location | |||||||||
| Address1: | 790 W ORANGE AVE | ||||||||
| Address2: | SUITE D | ||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603538858 | ||||||||
| FaxNumber: | 7605450248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 04/19/2019 | ||||||||
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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 | 174400000X | G55463 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00G554631 | 05 | CA | MEDICAID |