Healthcare Provider Details

I. General information

NPI: 1619969664
Provider Name (Legal Business Name): GENE E WYLL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: GENE E WYLL MD PA

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 N COIT RD SUITE 2115
RICHARDSON TX
75080-5457
US

IV. Provider business mailing address

610 N COIT RD SUITE 2115
RICHARDSON TX
75080-5457
US

V. Phone/Fax

Practice location:
  • Phone: 214-575-4455
  • Fax: 972-918-0480
Mailing address:
  • Phone: 214-575-4455
  • Fax: 972-918-0480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberD9731
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: