Provider Demographics
NPI:1548917172
Name:TRISTAN L WILD OD PLLC
Entity type:Organization
Organization Name:TRISTAN L WILD OD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRISTAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:512-263-9970
Mailing Address - Street 1:1700 RANCH ROAD 620 S STE A
Mailing Address - Street 2:
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-6246
Mailing Address - Country:US
Mailing Address - Phone:512-263-9970
Mailing Address - Fax:512-895-9903
Practice Address - Street 1:1700 RANCH ROAD 620 S STE A
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-6246
Practice Address - Country:US
Practice Address - Phone:512-263-9970
Practice Address - Fax:512-895-9903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty