Provider Demographics
NPI:1477623858
Name:WILD, MICHAEL R (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:WILD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3460 LAUDERDALE DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-7529
Mailing Address - Country:US
Mailing Address - Phone:804-360-2273
Mailing Address - Fax:804-360-7996
Practice Address - Street 1:3460 LAUDERDALE DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-7529
Practice Address - Country:US
Practice Address - Phone:804-360-2273
Practice Address - Fax:804-360-7996
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001090111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA54 1910925OtherTAX ID
VA181767OtherBCBS
VAU44197Medicare UPIN
VA00W487W87Medicare PIN