Provider Demographics
NPI:1275586083
Name:WILDE, CLAYTON S (MD)
Entity Type:Individual
Prefix:
First Name:CLAYTON
Middle Name:S
Last Name:WILDE
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 1:1220 EAST 3900 SOUTH
Mailing Address - Street 2:SUITE 3E
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124
Mailing Address - Country:US
Mailing Address - Phone:801-685-7188
Mailing Address - Fax:801-685-8116
Practice Address - Street 1:1220 EAST 3900 SOUTH
Practice Address - Street 2:SUITE 3E
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124
Practice Address - Country:US
Practice Address - Phone:801-685-7188
Practice Address - Fax:801-685-8116
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1694861205207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D07485Medicare UPIN