Healthcare Provider Details

I. General information

NPI: 1124182001
Provider Name (Legal Business Name): CHAD WILDE MD, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 09/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 E LOS ANGELES AVE SUITE 3 A
SIMI VALLEY CA
93065-2898
US

IV. Provider business mailing address

1350 E LOS ANGELES AVE SUITE 3 A
SIMI VALLEY CA
93065-2898
US

V. Phone/Fax

Practice location:
  • Phone: 805-504-4810
  • Fax:
Mailing address:
  • Phone: 805-504-4810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberA96633
License Number StateCA

VIII. Authorized Official

Name: DR. CHAD WILDE
Title or Position: PRESIDENT
Credential: MD, MS
Phone: 805-504-4810