MEDICARE: DR. HENRY E WILEY III M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ND0900X	Dermatopathology Physician	ME0025943	FL

General Provider Information

NPI Number	:	1023033719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HENRY E WILEY III M.D.

Provider Business Mailing Address
First Line	:	916 S GOLF VIEW ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33629-5222
Country	:	US
Telephone Number	:	813-251-3906
Fax Number	:

Provider Business Practice Location Address
First Line	:	1425 S HOWARD AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33606-3126
Country	:	US
Telephone Number	:	813-253-2635
Fax Number	:	813-254-7142

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	05/03/2012

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