Provider Demographics
NPI:1821296518
Name:WILDE, MATTHEW THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:WILDE
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 1:101 BODIN CIR
Mailing Address - Street 2:DGMC ANESTHESIA
Mailing Address - City:TRAVIS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:94535-1809
Mailing Address - Country:US
Mailing Address - Phone:707-423-5370
Mailing Address - Fax:
Practice Address - Street 1:101 BODIN CIR
Practice Address - Street 2:DAVID GRANT MEDICAL CENTER DEPT OF ANESTHESIA
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1809
Practice Address - Country:US
Practice Address - Phone:707-423-2355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA188085207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology