Provider Demographics
NPI:1376632620
Name:WYLIE, KEVIN D (DO)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
Last Name:WYLIE
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:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:6401 HARRIS PKWY STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-6100
Practice Address - Country:US
Practice Address - Phone:817-346-2525
Practice Address - Fax:817-294-1692
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1159208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138412505Medicaid
TX135003504Medicaid
TX1726078OtherUHC PIN
TX88701GOtherBCBSTX IND PIN
TX10023316OtherAMERIGROUP PIN
TX124194OtherSUPERIOR PIN
TX127377100OtherFIRSTCARE PIN
TX135003503Medicaid
1750369203OtherGRP NPI NUMBER
TX138412507Medicaid
TX5139588OtherAETNA PIN
TX00U87ZOtherBCBSTX GRP PIN
TX1088652OtherFIRSTHEALTH PIN
TX7068828OtherCIGNA PIN
TX138412505Medicaid
TX87161JMedicare PIN
TX7068828OtherCIGNA PIN