Provider Demographics
NPI:1295838134
Name:WILEY, TODD MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:MICHAEL
Last Name:WILEY
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 1:14210 SCOTTSLAWN RD
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43041-0001
Mailing Address - Country:US
Mailing Address - Phone:937-578-5555
Mailing Address - Fax:937-578-2642
Practice Address - Street 1:14210 SCOTTSLAWN RD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43041-0001
Practice Address - Country:US
Practice Address - Phone:937-578-5555
Practice Address - Fax:937-578-2642
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35079429W207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2280660Medicaid
OH9321901Medicare ID - Type Unspecified
OH2280660Medicaid