Provider Demographics
NPI:1790785467
Name:WILGARDE, DAVID STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:STEPHEN
Last Name:WILGARDE
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 1:148 W CAMINO ENCANTO
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-8910
Mailing Address - Country:US
Mailing Address - Phone:760-969-5200
Mailing Address - Fax:760-969-5201
Practice Address - Street 1:3001 E TAHQUITZ CANYON WAY STE 108
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-6900
Practice Address - Country:US
Practice Address - Phone:760-320-4292
Practice Address - Fax:760-322-9475
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2024-04-05
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
G744630225400000X
CAG74463208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G744632Medicaid
CA00G744632Medicaid
CA00G744632Medicaid
CABW1279404OtherDEA
CAF39892Medicare UPIN