Provider Demographics
NPI:1871582692
Name:WILD, ALAN P K (MD)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:P K
Last Name:WILD
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3635 VISTA AVE
Mailing Address - Street 2:P.O. BOX 15250
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2539
Mailing Address - Country:US
Mailing Address - Phone:314-577-8884
Mailing Address - Fax:314-268-5111
Practice Address - Street 1:3660 VISTA AVE
Practice Address - Street 2:STE. 312
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110
Practice Address - Country:US
Practice Address - Phone:314-977-5110
Practice Address - Fax:314-977-5119
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2009-11-20
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Provider Licenses
StateLicense IDTaxonomies
MOR9D17207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO040004991OtherRAILROAD MEDICARE
002010716Medicare ID - Type Unspecified
A28385Medicare UPIN