Healthcare Provider Details

I. General information

NPI: 1659463305
Provider Name (Legal Business Name): MARTA E WILD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PINE AVE
LONG BEACH CA
90813-3124
US

IV. Provider business mailing address

2509 ROCHELLE DR
FALLSTON MD
21047-2208
US

V. Phone/Fax

Practice location:
  • Phone: 562-595-1159
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD0032863
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number176524
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberD0032863
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: