Provider Demographics
NPI:1700820396
Name:WILD, WILLIAM ANTHONY (DO)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ANTHONY
Last Name:WILD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11318 GUM POINT RD
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-3172
Mailing Address - Country:US
Mailing Address - Phone:443-397-4167
Mailing Address - Fax:
Practice Address - Street 1:11318 GUM POINT RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-3172
Practice Address - Country:US
Practice Address - Phone:443-397-4167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010886L207P00000X
DEC2-0013043207P00000X
MDH0066476207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101038293002Medicaid
PA1010389293-02OtherAMERICHOICE BUCKS
PA101038293003Medicaid
PA07645OtherHEALTH PARTNERS
PA30017165OtherKEYSTONE MERCY
PA101038293001Medicaid
PA1010389293-01OtherAMERICHOICE FRANKFORD
PA1356562OtherCIGNA
PA1361074OtherHIGHMARK BLUE SHIELD
PA20045168OtherAMERIHEALTH MERCY
PA1010389293-03OtherAMERICHOICE TORRESDALE
PA2053335000OtherKEYSTONE IBC
PA452729OtherAETNA
PAP00146230Medicare ID - Type UnspecifiedRAILROAD MEDICARE
PA452729OtherAETNA
PA1010389293-03OtherAMERICHOICE TORRESDALE