Provider Demographics
NPI:1538422019
Name:WILDE, TREVOR GLADE (DO)
Entity type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:GLADE
Last Name:WILDE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 18
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:ID
Mailing Address - Zip Code:83445-0018
Mailing Address - Country:US
Mailing Address - Phone:208-356-4900
Mailing Address - Fax:208-624-4116
Practice Address - Street 1:335 E MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:SAINT ANTHONY
Practice Address - State:ID
Practice Address - Zip Code:83445-1546
Practice Address - Country:US
Practice Address - Phone:208-356-4900
Practice Address - Fax:208-624-4116
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0776207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine