Provider Demographics
NPI:1487860037
Name:WILDE, BRUCE JOEL (OD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:JOEL
Last Name:WILDE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BAY CLUB DR
Mailing Address - Street 2:4Y
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-2917
Mailing Address - Country:US
Mailing Address - Phone:718-229-0211
Mailing Address - Fax:
Practice Address - Street 1:ROSLYN EYE CENTER
Practice Address - Street 2:360 WILLIS AVE
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577
Practice Address - Country:US
Practice Address - Phone:516-484-8899
Practice Address - Fax:516-484-3311
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT003689 1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist