Provider Demographics
NPI:1205949765
Name:WILDS, RANDALL WADE (DC)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:WADE
Last Name:WILDS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5253 E COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32807
Mailing Address - Country:US
Mailing Address - Phone:407-275-9335
Mailing Address - Fax:407-275-9991
Practice Address - Street 1:5253 E COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807
Practice Address - Country:US
Practice Address - Phone:407-275-9335
Practice Address - Fax:407-275-9991
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7897111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G2628OtherBLUE CROSS BLUE SHIELD TX
TX8751B9Medicare ID - Type UnspecifiedINDIVIDUAL