Provider Demographics
NPI:1093774986
Name:WILDNER, RALF G (MD)
Entity Type:Individual
Prefix:DR
First Name:RALF
Middle Name:G
Last Name:WILDNER
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 1:100 NIKELLE LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH ABINGTON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18411-2866
Mailing Address - Country:US
Mailing Address - Phone:570-586-2624
Mailing Address - Fax:
Practice Address - Street 1:500 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-1508
Practice Address - Country:US
Practice Address - Phone:570-586-3587
Practice Address - Fax:570-586-0337
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD060289L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101359647Medicaid
G61040Medicare UPIN
002969Medicare ID - Type Unspecified