Provider Demographics
NPI:1972521581
Name:WILDE, JOSEPH LEE (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:LEE
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:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:TIMNATH
Mailing Address - State:CO
Mailing Address - Zip Code:80547
Mailing Address - Country:US
Mailing Address - Phone:970-673-1155
Mailing Address - Fax:
Practice Address - Street 1:4038 TIMBERLINE RD.
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525
Practice Address - Country:US
Practice Address - Phone:970-673-1155
Practice Address - Fax:970-673-4747
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO55030207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology