Physician Compare National (NPI:1407169865)

HEALTHCARE PROVIDER: BRANDON D WILDE D.P.M.

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1407169865
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	1456508746
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20120821000635
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	WILDE
	Individual professional last name
Provider First Name	BRANDON
	Individual professional first name
Provider Middle Name	DEAN
	Individual professional middle name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	COLLEGE OF PODIATRIC MED AND SURGERY, DES MOINES UNIVERSITY
	Individual professional's medical school
Graduation Year	2009
	Individual professional's medical school graduation year
Primary Specialty	PODIATRY
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Line 1 Street Address	1455 BENCH RD
	Group Practice or individual's line 1 address
Line 2 Street Address	SUITE B
	Group Practice or individual's line 2 address
City	POCATELLO
	Group Practice or individual's city
State	ID
	Group Practice or individual's state
Zip Code	832015084
	Group Practice or individual's zip code (9 digits when available)

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	131305
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	STEELE MEMORIAL MEDICAL CENTER
	Legal business name of hospital where individual professional provides service 1
Hospital Affiliation CCN 2	130028
	Medicare CCN of hospital where individual professional provides service 2
Hospital Affiliation LBN 2	PORTNEUF MEDICAL CENTER
	Legal business name of hospital where individual professional provides service 2
Professional Accepts Medicare Assignment	Y