Provider Demographics
NPI:1104890342
Name:WILDE, WAYNE G (OD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:G
Last Name:WILDE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7074 HIGHLAND RD STE A
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1500
Mailing Address - Country:US
Mailing Address - Phone:248-698-2000
Mailing Address - Fax:248-698-2655
Practice Address - Street 1:7074 HIGHLAND RD STE A
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1500
Practice Address - Country:US
Practice Address - Phone:248-698-2000
Practice Address - Fax:248-698-2655
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002777152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900F367410OtherBCBSM
MIF36741001Medicare PIN
MI900F367410OtherBCBSM
MI0944690001Medicare NSC