Provider Demographics
NPI:1356395081
Name:WILDE, GUSTAV C (MD)
Entity type:Individual
Prefix:
First Name:GUSTAV
Middle Name:C
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 1:161 IOTLA STREET
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:NC
Mailing Address - Zip Code:28734
Mailing Address - Country:US
Mailing Address - Phone:828-421-0460
Mailing Address - Fax:828-349-6767
Practice Address - Street 1:161 IOTLA STREET
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:NC
Practice Address - Zip Code:28734
Practice Address - Country:US
Practice Address - Phone:828-369-4244
Practice Address - Fax:828-349-6767
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32974207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC51937OtherMEDCOST
NC8987403Medicaid
NC87403OtherBCBSNC
NC87403OtherBCBSNC
NC8987403Medicaid