Healthcare Provider Details

I. General information

NPI: 1376632620
Provider Name (Legal Business Name): KEVIN D WYLIE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 HARRIS PKWY STE 100
FORT WORTH TX
76132-6100
US

IV. Provider business mailing address

PO BOX 733784
DALLAS TX
75373-3784
US

V. Phone/Fax

Practice location:
  • Phone: 817-346-2525
  • Fax: 817-294-1692
Mailing address:
  • Phone: 682-885-1855
  • Fax: 682-885-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberJ1159
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: