Provider Demographics
NPI:1114114550
Name:WILDER, STEPHANIE KRESCH (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:KRESCH
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:PO BOX 70368
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97475-0120
Mailing Address - Country:US
Mailing Address - Phone:541-485-2777
Mailing Address - Fax:541-246-2353
Practice Address - Street 1:3100 MARTIN LUTHER KING JR PKWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-7514
Practice Address - Country:US
Practice Address - Phone:541-868-9700
Practice Address - Fax:541-485-7392
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6360465-1205207V00000X
KYTP119207V00000X
ORMD176904207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500714052Medicaid