Provider Demographics
NPI:1760012959
Name:MYLEA N WILEY MD INC.
Entity type:Organization
Organization Name:MYLEA N WILEY MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MYLEA
Authorized Official - Middle Name:N
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-237-3242
Mailing Address - Street 1:2595 E PERRIN AVE
Mailing Address - Street 2:#114
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-5202
Mailing Address - Country:US
Mailing Address - Phone:559-455-8944
Mailing Address - Fax:559-436-4395
Practice Address - Street 1:2755 HERNDON AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6801
Practice Address - Country:US
Practice Address - Phone:559-324-4000
Practice Address - Fax:559-324-3744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-16
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A889170Medicaid