Healthcare Provider Details

I. General information

NPI: 1538104385
Provider Name (Legal Business Name): ASHLEY PAUL WILDE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9542 ARTESIA BLVD
BELLFLOWER CA
90706-6511
US

IV. Provider business mailing address

PO BOX 3999
TORRANCE CA
90510-3999
US

V. Phone/Fax

Practice location:
  • Phone: 562-925-8355
  • Fax: 562-925-4413
Mailing address:
  • Phone: 310-792-3914
  • Fax: 310-792-3621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG79378
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: