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NPI Code Detail

MEDICARE: WYLIE MASTERSON MOODY

MEDICARE: WYLIE MASTERSON MOODY
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207N00000XDermatology PhysicianV8697TX

General Provider Information

NPI Number : 1740920529
Entity Type Code : Individual
Provider Name (Legal Business Name) : WYLIE MASTERSON MOODY
Provider Business Mailing Address
First Line : 6404 NURSERY DR STE 201
Second Line :
City : VICTORIA
State : TX
Zip : 77904-1688
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 12141 RICHMOND AVE
Second Line :
City : HOUSTON
State : TX
Zip : 77082-2408
Country : US
Telephone Number : 281-558-3444
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/30/2022
Last Update Date : 03/12/2026

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Directions to “ WYLIE MASTERSON MOODY ” Practice Location

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