Provider Demographics
NPI:1124046040
Name:WYLLIE, JOSEPH A (DO)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:A
Last Name:WYLLIE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1377 SOUTH COUNTY TRAIL
Mailing Address - Street 2:
Mailing Address - City:EAST GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02818
Mailing Address - Country:US
Mailing Address - Phone:401-226-7590
Mailing Address - Fax:401-886-7571
Practice Address - Street 1:1377 SOUTH COUNTY TRAIL
Practice Address - Street 2:
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818
Practice Address - Country:US
Practice Address - Phone:401-226-7590
Practice Address - Fax:401-886-7571
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDO00420207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9003694Medicaid
RIF24140Medicare UPIN
RI9003694Medicaid