Provider Demographics
NPI:1962476333
Name:MCCOY, WANDA (MD)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:MCCOY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 W BURNSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-4015
Mailing Address - Country:US
Mailing Address - Phone:718-716-4400
Mailing Address - Fax:718-228-7471
Practice Address - Street 1:85 W BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4015
Practice Address - Country:US
Practice Address - Phone:718-716-4400
Practice Address - Fax:718-228-7471
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY155625208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY155625OtherLICENSE#
NYE20363Medicare UPIN