Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | 41165 | AZ |
N | 207XX0004X | Foot and Ankle Orthopaedic Surgeon | 41165 | AZ |
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 41165 | AZ |
NPI | 1619181856 |
---|---|
Provider Name | Dr. John James Wild III |
First Address | Tucson, AZ 85751-1630 |
Second Address | Tucson, AZ 85712-2805 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/05/2007 |
Last Update Date | 24/05/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
417281 | (05) | AZ |