Healthcare Provider Details

I. General information

NPI: 1740285741
Provider Name (Legal Business Name): JEUTI B WYLDE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 01/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 WALL ST SUITE 102
JEFFERSONVILLE IN
47130-3612
US

IV. Provider business mailing address

PO BOX 890631
CHARLOTTE NC
28289-0631
US

V. Phone/Fax

Practice location:
  • Phone: 812-282-2036
  • Fax: 812-282-2227
Mailing address:
  • Phone: 812-542-4921
  • Fax: 812-949-5966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01041261
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: