Provider Demographics
NPI:1851419048
Name:WILD, JEFFREY LEE (DC)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:LEE
Last Name:WILD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411B LAKESHORE RD
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53083-2902
Mailing Address - Country:US
Mailing Address - Phone:920-458-8886
Mailing Address - Fax:920-458-1128
Practice Address - Street 1:3411B LAKESHORE RD
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53083-2902
Practice Address - Country:US
Practice Address - Phone:920-458-8886
Practice Address - Fax:920-458-1128
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2080-012111N00000X
WI2080-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIT63669Medicare UPIN
WI75244Medicare ID - Type UnspecifiedCHIROPRACTIC