Healthcare Provider Details

I. General information

NPI: 1760771794
Provider Name (Legal Business Name): JAMES DEREK WYLIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2011
Last Update Date: 09/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5848 S FASHION BLVD
MURRAY UT
84107-6157
US

IV. Provider business mailing address

1888 SUN PEAK DR
PARK CITY UT
84098-6718
US

V. Phone/Fax

Practice location:
  • Phone: 801-314-4100
  • Fax:
Mailing address:
  • Phone: 216-333-5836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number55564
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number270960
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number8438015-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: