Provider Demographics
NPI:1669405924
Name:WYLEN, ESTHER LOUISE (MD)
Entity type:Individual
Prefix:
First Name:ESTHER
Middle Name:LOUISE
Last Name:WYLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5955 RAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34238-5160
Mailing Address - Country:US
Mailing Address - Phone:941-876-4360
Mailing Address - Fax:941-552-7605
Practice Address - Street 1:5955 RAND BLVD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34238-5160
Practice Address - Country:US
Practice Address - Phone:941-876-4360
Practice Address - Fax:941-552-7605
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82022207T00000X, 208D00000X, 208D00000X
OH35.068791208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021076300Medicaid
LA1684996Medicaid
LA1684996Medicaid
LA5W875D924Medicare ID - Type Unspecified
FLAL630ZMedicare PIN