Provider Demographics
NPI:1891759916
Name:WILD, MARK DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:WILD
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:2728 SUNSET BLVD STE 201
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4837
Practice Address - Country:US
Practice Address - Phone:803-254-1300
Practice Address - Fax:803-771-7597
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2024-01-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC20467207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC204674Medicaid
SCH380523922Medicare PIN
SC204674Medicaid
H38052Medicare UPIN