Provider Demographics
NPI:1902824063
Name:WILD, LAURIANNE G (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURIANNE
Middle Name:G
Last Name:WILD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1430 TULANE AVE
Mailing Address - Street 2:SL57
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2632
Mailing Address - Country:US
Mailing Address - Phone:504-988-5584
Mailing Address - Fax:504-988-3686
Practice Address - Street 1:1430 TULANE AVE
Practice Address - Street 2:SL57
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2632
Practice Address - Country:US
Practice Address - Phone:504-988-5584
Practice Address - Fax:504-988-3686
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.021069207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1991759Medicaid
LA5U523Medicare PIN
LA1991759Medicaid