Provider Demographics
NPI:1295997013
Name:WILDE, BENJAMIN B (DO)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:B
Last Name:WILDE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 HOWELL
Mailing Address - Street 2:
Mailing Address - City:WORLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82401
Mailing Address - Country:US
Mailing Address - Phone:307-347-2555
Mailing Address - Fax:307-347-9831
Practice Address - Street 1:1405 HOWELL
Practice Address - Street 2:
Practice Address - City:WORLAND
Practice Address - State:WY
Practice Address - Zip Code:82401
Practice Address - Country:US
Practice Address - Phone:307-347-2555
Practice Address - Fax:307-347-9831
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8661A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1295997013Medicaid
WYW24170Medicare UPIN