Provider Demographics
NPI:1396189296
Name:WILD, ELIZABETH S (MD, MS)
Entity Type:Individual
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First Name:ELIZABETH
Middle Name:S
Last Name:WILD
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Gender:F
Credentials:MD, MS
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Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:NEUROSURGERY
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-813-2482
Mailing Address - Fax:318-813-2491
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:NEUROSURGERY
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-813-2482
Practice Address - Fax:318-813-2491
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-22
Last Update Date:2020-07-01
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Provider Licenses
StateLicense IDTaxonomies
MI4301502104207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery