Healthcare Provider Details

I. General information

NPI: 1750308243
Provider Name (Legal Business Name): DONALD TODD WYLIE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 03/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 S FREYA ST. STE 220, WHITE FLAG BLDG
SPOKANE WA
99202-4867
US

IV. Provider business mailing address

104 S FREYA ST. STE 220, WHITE FLAG BLDG
SPOKANE WA
99202-4867
US

V. Phone/Fax

Practice location:
  • Phone: 509-535-5855
  • Fax: 509-535-3916
Mailing address:
  • Phone: 509-535-5855
  • Fax: 509-535-3916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number1528-TX
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: