Provider Demographics
NPI:1124182001
Name:CHAD WILDE MD, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:CHAD WILDE MD, A MEDICAL CORPORATION
Other - Org Name:SIMI PAIN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:WILDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MS
Authorized Official - Phone:805-504-4810
Mailing Address - Street 1:1350 E LOS ANGELES AVE
Mailing Address - Street 2:SUITE 3 A
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-2898
Mailing Address - Country:US
Mailing Address - Phone:805-504-4810
Mailing Address - Fax:
Practice Address - Street 1:1350 E LOS ANGELES AVE
Practice Address - Street 2:SUITE 3 A
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-2898
Practice Address - Country:US
Practice Address - Phone:805-504-4810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96633207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty