Provider Demographics
NPI:1467419135
Name:WILEY, PHILIP DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:DAVID
Last Name:WILEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1165 S CAMINO DEL RIO
Mailing Address - Street 2:STE 200
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-6824
Mailing Address - Country:US
Mailing Address - Phone:970-247-2920
Mailing Address - Fax:970-247-2923
Practice Address - Street 1:1165 S CAMINO DEL RIO
Practice Address - Street 2:STE 200
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303-6824
Practice Address - Country:US
Practice Address - Phone:970-247-2920
Practice Address - Fax:970-247-2923
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO35193207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01351931Medicaid
NMQ5374Medicaid
CON3028Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
CO01351931Medicaid
COG31159Medicare UPIN