Provider Demographics
NPI:1487970463
Name:WYLER VON BALLMOOS, MORITZ CASPER (MD/PHD/MPH)
Entity type:Individual
Prefix:DR
First Name:MORITZ
Middle Name:CASPER
Last Name:WYLER VON BALLMOOS
Suffix:
Gender:M
Credentials:MD/PHD/MPH
Other - Prefix:DR
Other - First Name:MORITZ
Other - Middle Name:
Other - Last Name:WYLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD/PHD/MPH
Mailing Address - Street 1:6550 FANNIN ST STE 1401
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2738
Mailing Address - Country:US
Mailing Address - Phone:713-441-5200
Mailing Address - Fax:
Practice Address - Street 1:6550 FANNIN ST STE 1401
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:713-441-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-01460208600000X
390200000X
TXR4499208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX379135201Medicaid