Provider Demographics
NPI:1518250489
Name:WILDE, JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
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 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-605-7171
Mailing Address - Fax:
Practice Address - Street 1:10666 N TORREY PINES RD # MS 116
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1027
Practice Address - Country:US
Practice Address - Phone:858-554-7993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-25
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA139800207XS0114X
MI4301098243207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery