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General NPI Number Information
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NPI Number | 1669516738
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Entity Type | Organization
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Legal Business Name | VALLEY FOOT & ANKLE, PC
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Dates
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Enumeration Date | 02/20/2007
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Last Update Date | 03/17/2018
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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 | 208-232-0006
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Provider Business Mailing 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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Authorized Official
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Title or Position | OWNER/PRACTIONER
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Name | DR. BRANDON DEAN WILDE
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Credential | DPM
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Telephone | 208-232-0006
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | P92
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License Number State | ID
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