Provider Demographics
NPI:1891744140
Name:WILDE, KIM L (MD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:L
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 1:1001 E SUPERIOR ST STE L401
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2207
Mailing Address - Country:US
Mailing Address - Phone:218-249-7960
Mailing Address - Fax:
Practice Address - Street 1:1001 E SUPERIOR ST STE L401
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802
Practice Address - Country:US
Practice Address - Phone:218-249-7960
Practice Address - Fax:218-249-7997
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD2534207R00000X
MN65959207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6000743Medicaid
SDS7967Medicare PIN
SDD25693Medicare UPIN
SD6000743Medicaid