Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207X00000X | Orthopaedic Surgeon | 4301098243 | MI |
N | 207XS0114X | Adult Reconstructive Orthopaedic Surgeon | A139800 | CA |
NPI | 1518250489 |
---|---|
Provider Name | Jeffrey Wilde |
First Address | San Diego, CA 92127-5705 |
Second Address | La Jolla, CA 92037-1027 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/05/2011 |
Last Update Date | 10/12/2019 |