Provider Demographics
NPI:1831238625
Name:WILD, WAYNE S (MD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:S
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 1:705 MOUNT AUBURN STREET
Mailing Address - Street 2:TUFTS HEALTH PLAN
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-1508
Mailing Address - Country:US
Mailing Address - Phone:617-972-9400
Mailing Address - Fax:617-972-9060
Practice Address - Street 1:705 MOUNT AUBURN STREET
Practice Address - Street 2:TUFTS HEALTH PLAN
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-1508
Practice Address - Country:US
Practice Address - Phone:617-972-9400
Practice Address - Fax:617-972-9060
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA36914207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine