Provider Demographics
NPI:1730374935
Name:WAYNE G. WILDE, O.D., P.C.
Entity type:Organization
Organization Name:WAYNE G. WILDE, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILDE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:248-698-2000
Mailing Address - Street 1:7074 HIGHLAND RD STE A
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1500
Mailing Address - Country:US
Mailing Address - Phone:248-698-2000
Mailing Address - Fax:248-698-2655
Practice Address - Street 1:7074 HIGHLAND RD STE A
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1500
Practice Address - Country:US
Practice Address - Phone:248-698-2000
Practice Address - Fax:248-698-2655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002777152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900F367410OtherBCBSM
MI=========OtherEIN
MI0944690001Medicare NSC
MI0F36741Medicare PIN