Provider Demographics
NPI:1740285741
Name:WYLDE, JEUTI B (MD)
Entity type:Individual
Prefix:DR
First Name:JEUTI
Middle Name:B
Last Name:WYLDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 890631
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-0631
Mailing Address - Country:US
Mailing Address - Phone:812-542-4921
Mailing Address - Fax:812-949-5966
Practice Address - Street 1:1035 WALL ST
Practice Address - Street 2:SUITE 102
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3612
Practice Address - Country:US
Practice Address - Phone:812-282-2036
Practice Address - Fax:812-282-2227
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN010412612084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100362930Medicaid
INM54226031Medicare PIN
IN100362930Medicaid