Provider Demographics
NPI:1972627867
Name:WILD, SUSANNE GERTRAUD (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSANNE
Middle Name:GERTRAUD
Last Name:WILD
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1300 N 12TH ST
Mailing Address - Street 2:#605
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2848
Mailing Address - Country:US
Mailing Address - Phone:602-839-4567
Mailing Address - Fax:602-839-2232
Practice Address - Street 1:1300 N 12TH ST
Practice Address - Street 2:#605
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2848
Practice Address - Country:US
Practice Address - Phone:602-839-4567
Practice Address - Fax:602-839-2232
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-18
Last Update Date:2012-12-26
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Provider Licenses
StateLicense IDTaxonomies
AZ35547207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ115223Medicare PIN