Provider Demographics
NPI:1265435184
Name:WYLL, SHELBY A (MD)
Entity type:Individual
Prefix:DR
First Name:SHELBY
Middle Name:A
Last Name:WYLL
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 1:1626 FOREST LANE
Mailing Address - Street 2:SUITE C
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042
Mailing Address - Country:US
Mailing Address - Phone:972-494-1451
Mailing Address - Fax:972-494-2105
Practice Address - Street 1:1626 FOREST LANE
Practice Address - Street 2:SUITE C
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042
Practice Address - Country:US
Practice Address - Phone:972-494-1451
Practice Address - Fax:972-494-2105
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2011-04-06
Deactivation Date:2006-03-29
Deactivation Code:
Reactivation Date:2006-12-21
Provider Licenses
StateLicense IDTaxonomies
TXD5258207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113485004Medicaid
00AJ92Medicare ID - Type Unspecified
TX113485004Medicaid