Provider Demographics
NPI:1083758056
Name:WILDER, GLORIA ANNONET (MD)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:ANNONET
Last Name:WILDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17956 SWANS CREEK LN
Mailing Address - Street 2:
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22026-4526
Mailing Address - Country:US
Mailing Address - Phone:202-302-3996
Mailing Address - Fax:
Practice Address - Street 1:2516 SHERIDAN RD SE STE A
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-5265
Practice Address - Country:US
Practice Address - Phone:202-610-6106
Practice Address - Fax:202-610-6107
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101055487208000000X
DCMD21918208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0294657 00Medicaid
VA6704701Medicaid
G40628Medicare UPIN
DC0294657 00Medicaid