Provider Demographics
NPI:1225689748
Name:WILD, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WILD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 MILLPOND STE 100
Mailing Address - Street 2:
Mailing Address - City:STANSBURY PARK
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9760
Mailing Address - Country:US
Mailing Address - Phone:435-843-3000
Mailing Address - Fax:435-843-3015
Practice Address - Street 1:220 MILLPOND STE 100
Practice Address - Street 2:
Practice Address - City:STANSBURY PARK
Practice Address - State:UT
Practice Address - Zip Code:84074-9760
Practice Address - Country:US
Practice Address - Phone:435-843-3000
Practice Address - Fax:435-843-3015
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2023-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRL16538207Q00000X
UT7546357-1205208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice