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General NPI Number Information
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NPI Number | 1225017817
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Entity Type | Individual
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Provider Name | WADE WALLACE WILDE MD
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Gender | Male
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Dates
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Enumeration Date | 01/11/2006
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Last Update Date | 11/23/2020
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Provider Practice Location Address
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Address Line | 1029 S TRIMBLE RD
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City | MANSFIELD
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State | OH
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Zip | 44906-3427
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Country | US
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Telephone | 419-521-2950
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Fax | 419-522-0837
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Provider Business Mailing Address
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Address Line | 1029 S TRIMBLE RD
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City | MANSFIELD
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State | OH
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Zip | 44906-3427
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Country | US
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Telephone | 419-521-2950
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Fax | 419-522-0837
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 18724
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License Number State | NE
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 35.074229
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License Number State | OH
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