=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699079129
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID WILD, MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2010
-----------------------------------------------------
Last Update Date | 12/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 344 VAN NOSTRAND AVE
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07631-4725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-971-7602
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 344 VAN NOSTRAND AVE
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07631-4725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DAVID WILD
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 917-971-7602
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 25MA08328000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------