Provider Demographics
NPI:1629347752
Name:WYCOCO, ALVIN
Entity Type:Individual
Prefix:
First Name:ALVIN
Middle Name:
Last Name:WYCOCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31464 POLO CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-7411
Mailing Address - Country:US
Mailing Address - Phone:973-757-3460
Mailing Address - Fax:
Practice Address - Street 1:163 VAN BUREN RD
Practice Address - Street 2:
Practice Address - City:CARIBOU
Practice Address - State:ME
Practice Address - Zip Code:04736-3567
Practice Address - Country:US
Practice Address - Phone:207-498-3111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114576207R00000X
TXQ2633207R00000X
390200000X
MEMD20530207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program