Provider Demographics
NPI:1356696595
Name:WILD, CHRISTOPHER ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:ROBERT
Last Name:WILD
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 1:4802 S. 109TH E. AVE
Mailing Address - Street 2:
Mailing Address - City:TUSLA
Mailing Address - State:OK
Mailing Address - Zip Code:74146
Mailing Address - Country:US
Mailing Address - Phone:918-392-1513
Mailing Address - Fax:918-392-1590
Practice Address - Street 1:4802 S. 109TH E. AVE
Practice Address - Street 2:
Practice Address - City:TUSLA
Practice Address - State:OK
Practice Address - Zip Code:74146
Practice Address - Country:US
Practice Address - Phone:918-392-1513
Practice Address - Fax:918-392-1590
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.131283207X00000X
OK37775207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200974040AMedicaid