Provider Demographics
NPI:1265669352
Name:WILTSE, RICHARD JACOB (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JACOB
Last Name:WILTSE
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 1:699 14TH ST
Mailing Address - Street 2:APT 348
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-7586
Mailing Address - Country:US
Mailing Address - Phone:701-240-1911
Mailing Address - Fax:
Practice Address - Street 1:2005 KNIGHT LANE BLDG H
Practice Address - Street 2:NAVY MEDICINE SUPPORT COMMAND ATTN: MEDICAL STAFF SERVI
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212-0140
Practice Address - Country:US
Practice Address - Phone:619-532-8038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXQ9092207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program