Provider Demographics
NPI:1508901810
Name:WILDE, MARY K (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:WILDE
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 1:9850 GENESEE AVE STE 510
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1213
Mailing Address - Country:US
Mailing Address - Phone:858-623-2345
Mailing Address - Fax:858-623-2343
Practice Address - Street 1:9850 GENESEE AVE STE 510
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1213
Practice Address - Country:US
Practice Address - Phone:858-623-2345
Practice Address - Fax:858-623-2343
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65602174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG65602CMedicare PIN