1497106348 NPI number — DR. ANGELA R WILD M.D., MPH

Table of content: DR. ANGELA R WILD M.D., MPH (NPI 1497106348)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497106348 NPI number — DR. ANGELA R WILD M.D., MPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILD
Provider First Name:
ANGELA
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D., MPH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1497106348
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3635 VISTA AVE
Provider Second Line Business Mailing Address:
ST. LOUIS UNIVERSITY, SURGERY EDUCATION 3FDT
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63110-2539
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-577-8317
Provider Business Mailing Address Fax Number:
314-268-5466

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 HAWKINS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IOWA CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52242-1009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-353-6360
Provider Business Practice Location Address Fax Number:
319-353-7006
Provider Enumeration Date:
06/22/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  2016015532 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: MD-48512 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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