Basic Information
| Provider Information | |||||||||
| NPI: | 1477015246 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILDE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | CHAMBERLAYNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BAYLOR PLZ | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770303498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137984951 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1504 BEN TAUB LOOP | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138732000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2019 | ||||||||
| LastUpdateDate: | 04/02/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | TX | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.