Provider Demographics
NPI:1528086311
Name:WILDBERG, BRADLEY DALE (DC)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:DALE
Last Name:WILDBERG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-1515
Mailing Address - Country:US
Mailing Address - Phone:715-748-2334
Mailing Address - Fax:715-748-1124
Practice Address - Street 1:333 N 8TH ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1515
Practice Address - Country:US
Practice Address - Phone:715-748-2334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1600-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38764400Medicaid
WI38987200OtherMEDICAID GROUP
WI38987200OtherMEDICAID GROUP
WI000170270Medicare ID - Type Unspecified