Provider Demographics
NPI:1194045583
Name:WILDE, JOHANNA MOON (MD)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:MOON
Last Name:WILDE
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 1:1401 FOUCHER ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-3515
Mailing Address - Country:US
Mailing Address - Phone:504-897-7011
Mailing Address - Fax:
Practice Address - Street 1:727 1/2 HENRY CLAY AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-5819
Practice Address - Country:US
Practice Address - Phone:985-320-5467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.205810207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine