Provider Demographics
NPI:1619969664
Name:WYLL, GENE E (MD)
Entity Type:Individual
Prefix:MR
First Name:GENE
Middle Name:E
Last Name:WYLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GENE
Other - Middle Name:E
Other - Last Name:WYLL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD PA
Mailing Address - Street 1:610 N COIT RD
Mailing Address - Street 2:SUITE 2115
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-5457
Mailing Address - Country:US
Mailing Address - Phone:214-575-4455
Mailing Address - Fax:972-918-0480
Practice Address - Street 1:610 N COIT RD
Practice Address - Street 2:SUITE 2115
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-5457
Practice Address - Country:US
Practice Address - Phone:214-575-4455
Practice Address - Fax:972-918-0480
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD9731207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B27694Medicare UPIN
AJ49Medicare ID - Type Unspecified