Provider Demographics
NPI:1750306502
Name:WYLIE, MARK W (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:WYLIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:6301 HARRIS PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4249
Mailing Address - Country:US
Mailing Address - Phone:817-433-3450
Mailing Address - Fax:817-294-6429
Practice Address - Street 1:6301 HARRIS PKWY STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4249
Practice Address - Country:US
Practice Address - Phone:817-433-3450
Practice Address - Fax:817-294-6429
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7265207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00166250OtherRAIL ROAD MEDICARE
TX161222802Medicaid
TX161222802Medicaid
TX432732YKPWMedicare PIN