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:
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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
StateLicense IDTaxonomies
MN65787207V00000X
MI4301067907207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI160B41011OtherBCBS MI
MI383445481OtherTAX ID
MI160055213OtherRR MEDICARE
MI4197610Medicaid
MI4197610Medicaid
MI160B41011OtherBCBS MI