Provider Demographics
NPI:1912900739
Name:WILDENBERG, HOPE A (MD)
Entity Type:Individual
Prefix:
First Name:HOPE
Middle Name:A
Last Name:WILDENBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1081 N CHINA LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-3130
Mailing Address - Country:US
Mailing Address - Phone:760-446-6404
Mailing Address - Fax:760-446-6415
Practice Address - Street 1:105 E SYDNOR AVE STE 100
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-5546
Practice Address - Country:US
Practice Address - Phone:760-446-6404
Practice Address - Fax:760-446-6415
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COG83457207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G834570Medicare PIN
CA00G834570OtherPTAN
CAG72605Medicare UPIN
CA770445816OtherFEDERAL TAX ID NUMBER
CAZZZ14433ZMedicare PIN