Provider Demographics
NPI:1720030026
Name:WYLIE, JOHN VOORHEES JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:VOORHEES
Last Name:WYLIE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:736 CAMBRIDGE ST
Mailing Address - Street 2:CCP4
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-2907
Mailing Address - Country:US
Mailing Address - Phone:617-789-3187
Mailing Address - Fax:
Practice Address - Street 1:736 CAMBRIDGE ST
Practice Address - Street 2:CCP4
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02135-2907
Practice Address - Country:US
Practice Address - Phone:617-789-3187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA214047207RC0001X, 207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAI66820Medicare UPIN