Provider Demographics
NPI:1750308243
Name:WYLIE, DONALD TODD (OD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:TODD
Last Name:WYLIE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 S FREYA ST.
Mailing Address - Street 2:STE 220, WHITE FLAG BLDG
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-4867
Mailing Address - Country:US
Mailing Address - Phone:509-535-5855
Mailing Address - Fax:509-535-3916
Practice Address - Street 1:104 S FREYA ST.
Practice Address - Street 2:STE 220, WHITE FLAG BLDG
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-4867
Practice Address - Country:US
Practice Address - Phone:509-535-5855
Practice Address - Fax:509-535-3916
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1528-TX152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2024842Medicaid
WAGAB20237Medicare ID - Type Unspecified
WAT02459Medicare UPIN