Healthcare Provider Details

I. General information

NPI: 1326088071
Provider Name (Legal Business Name): LORI ANN KOCUR-WILDE DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 REBEL RD
KING OF PRUSSIA PA
19406-2383
US

IV. Provider business mailing address

134 REBEL RD
KING OF PRUSSIA PA
19406-2383
US

V. Phone/Fax

Practice location:
  • Phone: 215-696-6078
  • Fax:
Mailing address:
  • Phone: 215-696-6078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberSC 003384L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: