Healthcare Provider Details

I. General information

NPI: 1912923830
Provider Name (Legal Business Name): RICHARD ALAN WILDE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 06/11/2021
Certification Date: 06/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1854 OAK GROVE BLVD
LUTZ FL
33559-8605
US

IV. Provider business mailing address

4033 TAMPA RD STE 101
OLDSMAR FL
34677-3224
US

V. Phone/Fax

Practice location:
  • Phone: 813-948-6133
  • Fax: 813-948-3460
Mailing address:
  • Phone: 813-854-2003
  • Fax: 813-855-3765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME82294
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: