Provider Demographics
NPI:1508860255
Name:WILDE, JAMES W (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:WILDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:331 S 3RD ST
Practice Address - Street 2:
Practice Address - City:LA CRESCENT
Practice Address - State:MN
Practice Address - Zip Code:55947-1328
Practice Address - Country:US
Practice Address - Phone:507-895-6610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20177207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30251700Medicaid
A94749Medicare UPIN
WI30251700Medicaid