MEDICARE: D. TODD WYLIE, O.D., INC.

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	261Q00000X	Clinic/Center	1528TX	WA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GAB20237	OTHER	WA	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730378308
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	D. TODD WYLIE, O.D., INC.

Provider Business Mailing Address
First Line	:	104 S FREYA STREET
Second Line	:	SUITE 220, WHITE FLAG BLDG
City	:	SPOKANE
State	:	WA
Zip	:	99202-4867
Country	:	US
Telephone Number	:	509-535-5855
Fax Number	:	509-535-3916

Provider Business Practice Location Address
First Line	:	104 S FREYA STREET
Second Line	:	SUITE 220, WHITE FLAG BLDG
City	:	SPOKANE
State	:	WA
Zip	:	99202-4867
Country	:	US
Telephone Number	:	509-535-5855
Fax Number	:	509-535-3916

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DONALD TODD WYLIE
Credential	:	OD
Telephone Number	:	509-535-5855

Provider Enumeration Date	:	10/19/2007
Last Update Date	:	03/21/2019

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