Healthcare Provider Details

I. General information

NPI: 1669495644
Provider Name (Legal Business Name): DANIEL M WILD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 05/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 DUKE MEDICINE CIR
DURHAM NC
27710-4000
US

IV. Provider business mailing address

5213 S ALSTON AVE
DURHAM NC
27713-4430
US

V. Phone/Fax

Practice location:
  • Phone: 919-684-8111
  • Fax:
Mailing address:
  • Phone: 919-620-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number227320
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2009-00744
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: