Provider Demographics
NPI:1912989187
Name:WILD, DOROTHEA (MD)
Entity Type:Individual
Prefix:
First Name:DOROTHEA
Middle Name:
Last Name:WILD
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 1:130 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1326
Mailing Address - Country:US
Mailing Address - Phone:203-732-7325
Mailing Address - Fax:203-732-1539
Practice Address - Street 1:130 DIVISION ST
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-1326
Practice Address - Country:US
Practice Address - Phone:203-732-7325
Practice Address - Fax:203-732-1539
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040387207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COH76436Medicare UPIN