Provider Demographics
NPI:1639130669
Name:WILE, PETER BARTHOLOMEW (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:BARTHOLOMEW
Last Name:WILE
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 1:4060 4TH AVE
Mailing Address - Street 2:SUITE 700
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2116
Mailing Address - Country:US
Mailing Address - Phone:619-299-8500
Mailing Address - Fax:619-297-1443
Practice Address - Street 1:4060 4TH AVE
Practice Address - Street 2:SUITE 700
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2116
Practice Address - Country:US
Practice Address - Phone:619-299-8500
Practice Address - Fax:619-297-1443
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44721207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G447210Medicaid
CA00G447210Medicaid
CAWG44721BMedicare ID - Type Unspecified