Healthcare Provider Details

I. General information

NPI: 1730378308
Provider Name (Legal Business Name): D. TODD WYLIE, O.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2007
Last Update Date: 03/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 S FREYA STREET SUITE 220, WHITE FLAG BLDG
SPOKANE WA
99202-4867
US

IV. Provider business mailing address

104 S FREYA STREET SUITE 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 Code261Q00000X
TaxonomyClinic/Center
License Number1528TX
License Number StateWA

VIII. Authorized Official

Name: DR. DONALD TODD WYLIE
Title or Position: OWNER
Credential: OD
Phone: 509-535-5855