Provider Demographics
NPI:1457561912
Name:WYLIE, JOHN D (MD, PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:WYLIE
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 W CREEK RD STE 35
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2133
Mailing Address - Country:US
Mailing Address - Phone:216-986-2915
Mailing Address - Fax:216-986-2915
Practice Address - Street 1:6100 W CREEK RD STE 35
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2133
Practice Address - Country:US
Practice Address - Phone:216-986-2915
Practice Address - Fax:216-986-2915
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD345842085R0202X
NC2010-007002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC1532Medicaid
NC5919470Medicaid
OHH214822OtherMEDICARE PTAN