Provider Demographics
NPI:1457444291
Name:WILD, ANNE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:MARIE
Last Name:WILD
Suffix:
Gender:F
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:PO BOX 8100
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97303-0900
Mailing Address - Country:US
Mailing Address - Phone:503-399-2424
Mailing Address - Fax:503-375-7432
Practice Address - Street 1:2020 CAPITOL ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-0644
Practice Address - Country:US
Practice Address - Phone:503-399-2424
Practice Address - Fax:503-375-7432
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14110207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR134407Medicaid
ORR180995Medicare PIN
OR134407Medicaid
OR134407Medicaid