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General NPI Number Information
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NPI Number | 1407169865
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Entity Type | Individual
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Provider Name | BRANDON D WILDE D.P.M.
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Gender | Male
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Dates
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Enumeration Date | 07/14/2010
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Last Update Date | 03/05/2026
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Provider Practice Location Address
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Address Line | 1455 BENCH RD STE B
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City | POCATELLO
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State | ID
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Zip | 83201-5084
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Country | US
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Telephone | 208-232-0006
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Fax | 208-233-8771
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Provider Business Mailing Address
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Address Line | 1455 BENCH RD SUITE B
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City | POCATELLO
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State | ID
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Zip | 83201-5083
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Country | US
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Telephone | 208-232-0006
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Fax | 208-233-8771
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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 | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | P-217
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License Number State | ID
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