Healthcare Provider Details

I. General information

NPI: 1013190693
Provider Name (Legal Business Name): YVETTE KIMBERLY WILD M.D., M.P.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: YVETTE WILD KOENIG MD

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 16TH ST 5TH FLOOR; BOX 0136
SAN FRANCISCO CA
94158-2549
US

IV. Provider business mailing address

550 16TH ST 5TH FLOOR; BOX 0136
SAN FRANCISCO CA
94158-2549
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-5892
  • Fax:
Mailing address:
  • Phone: 415-476-5892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA102785
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: