Provider Demographics
NPI:1760495097
Name:WYDILA, MICHAEL (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:WYDILA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 PHILADELPHIA PIKE
Mailing Address - Street 2:SUITE A6
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19809
Mailing Address - Country:US
Mailing Address - Phone:302-798-8070
Mailing Address - Fax:302-798-5902
Practice Address - Street 1:1400 PHILADELPHIA PIKE
Practice Address - Street 2:SUITE A6
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19809
Practice Address - Country:US
Practice Address - Phone:302-798-8070
Practice Address - Fax:302-798-5902
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10005759207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
2625833000OtherKEYSTONE
4620757OtherAETNA
DE1000024676Medicaid
DE1000024676Medicaid
G02212M01Medicare ID - Type Unspecified