Provider Demographics
NPI:1225017817
Name:WILDE, WADE WALLACE (MD)
Entity Type:Individual
Prefix:DR
First Name:WADE
Middle Name:WALLACE
Last Name:WILDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:WADE
Other - Middle Name:WALLACE
Other - Last Name:WILDE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1029 S TRIMBLE RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-3427
Mailing Address - Country:US
Mailing Address - Phone:419-521-2950
Mailing Address - Fax:419-522-0837
Practice Address - Street 1:1029 S TRIMBLE RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-3427
Practice Address - Country:US
Practice Address - Phone:419-521-2950
Practice Address - Fax:419-522-0837
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE18724208000000X
OH35.074229208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics