Healthcare Provider Details

I. General information

NPI: 1467419135
Provider Name (Legal Business Name): PHILIP DAVID WILEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 08/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 S CAMINO DEL RIO STE 200
DURANGO CO
81303-6824
US

IV. Provider business mailing address

1165 S CAMINO DEL RIO STE 200
DURANGO CO
81303-6824
US

V. Phone/Fax

Practice location:
  • Phone: 970-247-2920
  • Fax: 970-247-2923
Mailing address:
  • Phone: 970-247-2920
  • Fax: 970-247-2923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number35193
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: