Provider Demographics
NPI:1063483683
Name:WILDMAN, JANET V (DO)
Entity Type:Individual
Prefix:DR
First Name:JANET
Middle Name:V
Last Name:WILDMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5N380 RONSU LN
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-6216
Mailing Address - Country:US
Mailing Address - Phone:630-584-4860
Mailing Address - Fax:
Practice Address - Street 1:970 N 5TH AVE
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1227
Practice Address - Country:US
Practice Address - Phone:630-584-1950
Practice Address - Fax:630-584-8994
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-64686208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC46176Medicare UPIN