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General NPI Number Information
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NPI Number | 1992737704
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Entity Type | Individual
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Provider Name | TODD WILLIAM WILD OD
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Gender | Male
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Dates
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Enumeration Date | 07/06/2006
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Last Update Date | 11/30/2021
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Provider Practice Location Address
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Address Line | 415 E ANN ST
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City | WEYAUWEGA
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State | WI
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Zip | 54983-8532
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Country | US
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Telephone | 920-867-3131
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Fax | 920-867-3408
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Provider Business Mailing Address
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Address Line | PO BOX 350
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City | WEYAUWEGA
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State | WI
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Zip | 54983-0350
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Country | US
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Telephone | 920-867-3131
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Fax | 920-867-3408
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2346
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License Number State | WI
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