Provider Demographics
NPI: | 1164490611 |
---|---|
Name: | WILDER, JEFFREY W (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | JEFFREY |
Middle Name: | W |
Last Name: | WILDER |
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: | 14700 LAKE SHORE DRIVE |
Mailing Address - Street 2: | |
Mailing Address - City: | CHARLEVOIX |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 49720-1930 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 231-547-4024 |
Mailing Address - Fax: | 231-547-8088 |
Practice Address - Street 1: | 14651 W UPRIGHT ST |
Practice Address - Street 2: | |
Practice Address - City: | CHARLEVOIX |
Practice Address - State: | MI |
Practice Address - Zip Code: | 49720-1266 |
Practice Address - Country: | US |
Practice Address - Phone: | 231-547-4477 |
Practice Address - Fax: | 231-547-4753 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-03-10 |
Last Update Date: | 2023-09-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MN | 65787 | 207V00000X |
MI | 4301067907 | 207V00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MI | 160B41011 | Other | BCBS MI |
MI | 383445481 | Other | TAX ID |
MI | 160055213 | Other | RR MEDICARE |
MI | 4197610 | Medicaid | |
MI | 4197610 | Medicaid | |
MI | 160B41011 | Other | BCBS MI |