Provider Demographics
NPI:1285616375
Name:WILDE, CORIN Q (DPM)
Entity type:Individual
Prefix:DR
First Name:CORIN
Middle Name:Q
Last Name:WILDE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 E CENTENNIAL DR
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-6505
Mailing Address - Country:US
Mailing Address - Phone:620-231-5940
Mailing Address - Fax:620-231-5948
Practice Address - Street 1:407 E CENTENNIAL DR
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-6505
Practice Address - Country:US
Practice Address - Phone:620-231-5940
Practice Address - Fax:620-231-5948
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12-00315213ES0103X
MO2000168834213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSUMWAOther0638544
KS114056OtherBLUE CROSS
KSUMWAOther0638544
KS114056OtherBLUE CROSS
KS114056Medicare ID - Type Unspecified