Provider Demographics
NPI:1427807692
Name:DOUGLASS, WYLIE (NP)
Entity type:Individual
Prefix:
First Name:WYLIE
Middle Name:
Last Name:DOUGLASS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 FAIRFIELD WAY
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-8609
Mailing Address - Country:US
Mailing Address - Phone:909-731-4413
Mailing Address - Fax:
Practice Address - Street 1:500 W SAN BERNARDINO RD
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91722-3797
Practice Address - Country:US
Practice Address - Phone:626-960-2326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-18
Last Update Date:2024-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95030099207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine