Provider Demographics
NPI:1023144177
Name:WILDE, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:WILDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E 80TH ST
Mailing Address - Street 2:APT 32A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-0655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:61 E 77TH ST
Practice Address - Street 2:LENOX HILL RADIOLOGY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1817
Practice Address - Country:US
Practice Address - Phone:212-772-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-25
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25148712085R0202X
DEC7-00029302085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology