Provider Demographics
NPI:1164656716
Name:WILD, TRISTAN LEIGH (OD)
Entity Type:Individual
Prefix:DR
First Name:TRISTAN
Middle Name:LEIGH
Last Name:WILD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7201 RANCH ROAD 2222
Mailing Address - Street 2:#2116
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730-3208
Mailing Address - Country:US
Mailing Address - Phone:901-626-4940
Mailing Address - Fax:
Practice Address - Street 1:1700 RANCH ROAD 620 S
Practice Address - Street 2:#A
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-6245
Practice Address - Country:US
Practice Address - Phone:512-263-9970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-12
Last Update Date:2009-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7438T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist