Healthcare Provider Details

I. General information

NPI: 1922314145
Provider Name (Legal Business Name): BLAKE ANDREW WYLIE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2010
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23181 VERDUGO DR STE 103A
LAGUNA HILLS CA
92653-1313
US

IV. Provider business mailing address

2721 WASHINGTON STREET
JULIAN CA
92036
US

V. Phone/Fax

Practice location:
  • Phone: 949-366-1053
  • Fax:
Mailing address:
  • Phone: 760-765-1223
  • Fax: 760-765-1278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A11088
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: