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NPI Code Detail

MEDICARE: DR. WADE WALLACE WILDE MD

MEDICARE: DR. WADE WALLACE WILDE MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208000000XPediatrics Physician18724NE
2208000000XPediatrics Physician35.074229OH

General Provider Information

NPI Number : 1225017817
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. WADE WALLACE WILDE MD
Provider Business Mailing Address
First Line : 1029 S TRIMBLE RD
Second Line :
City : MANSFIELD
State : OH
Zip : 44906-3427
Country : US
Telephone Number : 419-521-2950
Fax Number : 419-522-0837
Provider Business Practice Location Address
First Line : 1029 S TRIMBLE RD
Second Line :
City : MANSFIELD
State : OH
Zip : 44906-3427
Country : US
Telephone Number : 419-521-2950
Fax Number : 419-522-0837
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/11/2006
Last Update Date : 11/23/2020

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