Provider Demographics
NPI:1407169865
Name:WILDE, BRANDON D (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:D
Last Name:WILDE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 BENCH RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5083
Mailing Address - Country:US
Mailing Address - Phone:208-232-0006
Mailing Address - Fax:208-233-8771
Practice Address - Street 1:1455 BENCH RD STE B
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5084
Practice Address - Country:US
Practice Address - Phone:208-232-0006
Practice Address - Fax:208-233-8771
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-217213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1407169865Medicaid
MOP01271994OtherRAILROAD MEDICARE
MO149630009Medicare PIN