Provider Demographics
NPI:1912107764
Name:WILD, JASON R (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:R
Last Name:WILD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:175 S UNION BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3126
Mailing Address - Country:US
Mailing Address - Phone:719-365-1950
Mailing Address - Fax:719-365-1951
Practice Address - Street 1:175 S UNION BLVD STE 310
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3126
Practice Address - Country:US
Practice Address - Phone:719-365-1950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ38028207X00000X
CODR.0062822207X00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery