Healthcare Provider Details

I. General information

NPI: 1265435184
Provider Name (Legal Business Name): SHELBY A WYLL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 04/06/2011
Certification Date:
Deactivation Date: 03/29/2006
Reactivation Date: 12/21/2006

III. Provider practice location address

1626 FOREST LANE SUITE C
GARLAND TX
75042
US

IV. Provider business mailing address

1626 FOREST LANE SUITE C
GARLAND TX
75042
US

V. Phone/Fax

Practice location:
  • Phone: 972-494-1451
  • Fax: 972-494-2105
Mailing address:
  • Phone: 972-494-1451
  • Fax: 972-494-2105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberD5258
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: