Provider Demographics
NPI:1083654198
Name:WILDER, ROBERT BRENT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:BRENT
Last Name:WILDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3881 E SMITH RD
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-8771
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18697 BAGLEY RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-3417
Practice Address - Country:US
Practice Address - Phone:440-816-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35042804W207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0427710Medicaid
OH942460636082OtherCARESOURCE
OHP00221626OtherMEDICARE RR-GA
OHA79495Medicare UPIN
OHP00221626OtherMEDICARE RR-GA