Healthcare Provider Details

I. General information

NPI: 1831171180
Provider Name (Legal Business Name): JOHN W. WYLLIE III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N OAK AVE
MARSHFIELD WI
54449-5702
US

IV. Provider business mailing address

1000 N OAK AVE
MARSHFIELD WI
54449-5703
US

V. Phone/Fax

Practice location:
  • Phone: 715-387-5511
  • Fax:
Mailing address:
  • Phone: 715-387-5511
  • Fax: 304-517-1404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number35084546
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number36803
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number73267
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number23086
License Number StateWV
# 5
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number3816
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: