Healthcare Provider Details

I. General information

NPI: 1386708709
Provider Name (Legal Business Name): JOEL WYSE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 W BETHANY HOME RD
PHOENIX AZ
85015-2507
US

IV. Provider business mailing address

11103 WEST AVE STE 6
SAN ANTONIO TX
78213-1370
US

V. Phone/Fax

Practice location:
  • Phone: 602-249-3057
  • Fax: 602-249-1420
Mailing address:
  • Phone: 210-524-6803
  • Fax: 210-524-6587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number263
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: