Provider Demographics
NPI:1710159132
Name:WILD, HERBERT FRANK (OD)
Entity Type:Individual
Prefix:DR
First Name:HERBERT
Middle Name:FRANK
Last Name:WILD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3175 SATELLITE BLVD
Mailing Address - Street 2:BUILDING 600 SUITE 175
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-9019
Mailing Address - Country:US
Mailing Address - Phone:770-622-9610
Mailing Address - Fax:770-622-2607
Practice Address - Street 1:3175 SATELLITE BLVD
Practice Address - Street 2:BUILDING 600 SUITE 175
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-9019
Practice Address - Country:US
Practice Address - Phone:770-622-9610
Practice Address - Fax:770-622-2607
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT0001872152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist