Basic Information
| Provider Information | |||||||||
| NPI: | 1790785467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILGARDE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | STEPHEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 148 W CAMINO ENCANTO | ||||||||
| Address2: | |||||||||
| City: | PALM SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922648910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609695200 | ||||||||
| FaxNumber: | 7609695201 | ||||||||
| Practice Location | |||||||||
| Address1: | 3001 E TAHQUITZ CANYON WAY STE 108 | ||||||||
| Address2: | |||||||||
| City: | PALM SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922626900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603204292 | ||||||||
| FaxNumber: | 7603229475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 04/06/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/21/2006 | ||||||||
| NPIReactivationDate: | 03/29/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | G744630 | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 208VP0000X | G74463 | CA | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | BW1279404 | 01 | CA | DEA | OTHER | 00G744632 | 05 | CA | MEDICAID |