Provider Demographics
NPI:1659463305
Name:WILD, MARTA E (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTA
Middle Name:E
Last Name:WILD
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 1:2509 ROCHELLE DR
Mailing Address - Street 2:
Mailing Address - City:FALLSTON
Mailing Address - State:MD
Mailing Address - Zip Code:21047-2208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 PINE AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3124
Practice Address - Country:US
Practice Address - Phone:562-595-1159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00728632084P0800X, 2084P0804X
CA1765242084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF74402Medicare UPIN
MDC032B701Medicare ID - Type Unspecified