Healthcare Provider Details

I. General information

NPI: 1497909576
Provider Name (Legal Business Name): JEUTI B. WYLDE, MD PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2008
Last Update Date: 05/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 E. 10TH ST.
JEFFERSONVILLE IN
47130-4227
US

IV. Provider business mailing address

PO BOX 128
OTISCO IN
47163-0128
US

V. Phone/Fax

Practice location:
  • Phone: 812-282-2036
  • Fax: 812-282-2277
Mailing address:
  • Phone: 812-282-2036
  • Fax: 812-282-2277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01041261A
License Number StateIN

VIII. Authorized Official

Name: JEUTI B. WYLDE
Title or Position: OWNER/OPERATOR
Credential: MD
Phone: 812-282-2036