MEDICARE: DR. MARK C. WILDE PSY.D.

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
1	103G00000X	Clinical Neuropsychologist	25025	TX
2	2084N0600X	Clinical Neurophysiology Physician	25025	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	89680A	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1730148925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK C. WILDE PSY.D.

Provider Business Mailing Address
First Line	:	13300 HARGRAVE RD
Second Line	:	SUITE 505
City	:	HOUSTON
State	:	TX
Zip	:	77070-4373
Country	:	US
Telephone Number	:	281-737-1167
Fax Number	:	281-469-1460

Provider Business Practice Location Address
First Line	:	13300 HARGRAVE RD
Second Line	:	SUITE 505
City	:	HOUSTON
State	:	TX
Zip	:	77070-4373
Country	:	US
Telephone Number	:	281-737-1167
Fax Number	:	281-469-1460

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/17/2006
Last Update Date	:	02/27/2017

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