1518515683 NPI number — JEFFREY WILDE MD PLLC

Table of content: (NPI 1518515683)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518515683 NPI number — JEFFREY WILDE MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFREY WILDE MD PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WILDE DESERT FAMILY MEDICINE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518515683
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2585 E WILCOX DR STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIERRA VISTA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85635-2822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-255-5475
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 EL CAMINO REAL BLDG 11
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIERRA VISTA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85635-2860
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-255-5475
Provider Business Practice Location Address Fax Number:
855-801-7998
Provider Enumeration Date:
08/30/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WILDE
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
VIRGIL
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
520-255-5475

Provider Taxonomy Codes

  • Taxonomy code: 133N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WL0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 552797 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 113039800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".