Provider Demographics
NPI:1033176060
Name:WILDING, JONATHAN W (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:W
Last Name:WILDING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:7926 PRESTON HWY
Practice Address - Street 2:SUITE 208
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3848
Practice Address - Country:US
Practice Address - Phone:502-968-3010
Practice Address - Fax:502-968-0035
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY27444207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1055818OtherPASSPORT / NCMA
2433815000OtherPASSPORT ADVANTAGE / NCMA
008890OtherSIHO / NCMA
00000050941OtherANTHEM / NCMA
KY64274442Medicaid
1198266OtherCHA / NCMA
000023035AOtherHUMANA / NCMA
KY110161205OtherMEDICARE RAILROAD
7107709003OtherCIGNA / NCMA
KY64274442Medicaid
1055818OtherPASSPORT / NCMA