Provider Demographics
NPI:1053412908
Name:WILD, RICHARD EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:EDWARD
Last Name:WILD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1275 OAK GROVE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-2737
Mailing Address - Country:US
Mailing Address - Phone:404-315-6110
Mailing Address - Fax:404-315-6074
Practice Address - Street 1:1275 OAK GROVE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-2737
Practice Address - Country:US
Practice Address - Phone:404-315-6110
Practice Address - Fax:404-315-6074
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA022194207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine