Provider Demographics
NPI:1659343291
Name:WILD, JAMES (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:WILD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PO BOX 2207
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78298-2207
Mailing Address - Country:US
Mailing Address - Phone:210-615-9990
Mailing Address - Fax:210-615-9909
Practice Address - Street 1:14615 SAN PEDRO
Practice Address - Street 2:STE # 105
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-4321
Practice Address - Country:US
Practice Address - Phone:210-404-0020
Practice Address - Fax:210-404-0325
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXE4114207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C23470Medicare UPIN