Provider Demographics
NPI:1679578207
Name:WILD, MARK J (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:WILD
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Gender:M
Credentials:MD
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Mailing Address - Street 1:615 W MACPHAIL RD
Mailing Address - Street 2:STE 106
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-4393
Mailing Address - Country:US
Mailing Address - Phone:410-638-8900
Mailing Address - Fax:410-638-8915
Practice Address - Street 1:2 NORTH AVE
Practice Address - Street 2:STE 101
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-2303
Practice Address - Country:US
Practice Address - Phone:410-838-6434
Practice Address - Fax:410-838-4250
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2012-12-10
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Provider Licenses
StateLicense IDTaxonomies
MDD35522207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD778171700Medicaid
MD102L797AMedicare ID - Type Unspecified
MD778171700Medicaid