Healthcare Provider Details

I. General information

NPI: 1356348759
Provider Name (Legal Business Name): WYLIE EDWARD NEWTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950A S. ENOTA DRIVE
GAINESVILLE GA
30501-2439
US

IV. Provider business mailing address

PO BOX 742616
ATLANTA GA
30374-2616
US

V. Phone/Fax

Practice location:
  • Phone: 678-450-8969
  • Fax: 678-450-8957
Mailing address:
  • Phone: 770-219-8420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number064875
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: