Provider Demographics
NPI:1326088071
Name:KOCUR-WILDE, LORI ANN (DPM)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:KOCUR-WILDE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 REBEL RD
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-2383
Mailing Address - Country:US
Mailing Address - Phone:215-696-6078
Mailing Address - Fax:
Practice Address - Street 1:134 REBEL RD
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-2383
Practice Address - Country:US
Practice Address - Phone:215-696-6078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC 003384L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0431485000OtherINDEPENDENCE BLUE CROSS
PA0431485000OtherAMERI HEALTH PERS CH
PA608729OtherHIGHMARK BLUE CROSS BLUE SHIELD
PA608729OtherHIGHMARK BLUE CROSS BLUE SHIELD
PA608729Medicare PIN