Healthcare Provider Details

I. General information

NPI: 1790785467
Provider Name (Legal Business Name): DAVID STEPHEN WILGARDE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 06/02/2024
Certification Date: 06/02/2024
Deactivation Date: 03/21/2006
Reactivation Date: 03/29/2006

III. Provider practice location address

3001 E TAHQUITZ CANYON WAY STE 108
PALM SPRINGS CA
92262-6900
US

IV. Provider business mailing address

148 W CAMINO ENCANTO
PALM SPRINGS CA
92264-8910
US

V. Phone/Fax

Practice location:
  • Phone: 760-320-4292
  • Fax: 760-322-9475
Mailing address:
  • Phone: 760-969-5200
  • Fax: 760-969-5201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberG74463
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberG744630
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: