1124182001 NPI number — CHAD WILDE MD, A MEDICAL CORPORATION

Table of content: (NPI 1124182001)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124182001 NPI number — CHAD WILDE MD, A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHAD WILDE MD, A MEDICAL CORPORATION
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:
Provider Other Organization Name Type Code:
6
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:
1124182001
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1350 E LOS ANGELES AVE
Provider Second Line Business Mailing Address:
SUITE 3 A
Provider Business Mailing Address City Name:
SIMI VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93065-2898
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-504-4810
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1350 E LOS ANGELES AVE
Provider Second Line Business Practice Location Address:
SUITE 3 A
Provider Business Practice Location Address City Name:
SIMI VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93065-2898
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-504-4810
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILDE
Authorized Official First Name:
CHAD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
805-504-4810

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  A96633 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com