Provider Demographics
NPI:1164468443
Name:WILDER, MARINA S (MD)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:S
Last Name:WILDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARINA
Other - Middle Name:S
Other - Last Name:WILDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1341 CANTON RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6056
Mailing Address - Country:US
Mailing Address - Phone:770-422-0517
Mailing Address - Fax:678-638-7015
Practice Address - Street 1:61 WHITCHER ST NE
Practice Address - Street 2:SUITE 2150
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1176
Practice Address - Country:US
Practice Address - Phone:770-422-4268
Practice Address - Fax:770-422-2950
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042000208000000X, 163WW0000X
GA0-420002083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No163WW0000XNursing Service ProvidersRegistered NurseWound Care