Provider Demographics
NPI:1518515683
Name:JEFFREY WILDE MD PLLC
Entity Type:Organization
Organization Name:JEFFREY WILDE MD PLLC
Other - Org Name:WILDE DESERT FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:VIRGIL
Authorized Official - Last Name:WILDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-255-5475
Mailing Address - Street 1:2585 E WILCOX DR STE A
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2822
Mailing Address - Country:US
Mailing Address - Phone:520-255-5475
Mailing Address - Fax:
Practice Address - Street 1:302 EL CAMINO REAL BLDG 11
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2860
Practice Address - Country:US
Practice Address - Phone:520-255-5475
Practice Address - Fax:855-801-7998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-30
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ552797Medicaid