Provider Demographics
NPI:1730148925
Name:WILDE, MARK C (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:C
Last Name:WILDE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:13300 HARGRAVE RD
Mailing Address - Street 2:SUITE 505
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-4373
Mailing Address - Country:US
Mailing Address - Phone:281-737-1167
Mailing Address - Fax:281-469-1460
Practice Address - Street 1:13300 HARGRAVE RD
Practice Address - Street 2:SUITE 505
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-4373
Practice Address - Country:US
Practice Address - Phone:281-737-1167
Practice Address - Fax:281-469-1460
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX25025103G00000X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102648606Medicaid
TX89680AOtherBCBS
TX89680AOtherBCBS
TX431428ZSWDMedicare PIN