Provider Demographics
NPI:1275562118
Name:WILDER, CHARLES ROMEO II (OD,FAAO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ROMEO
Last Name:WILDER
Suffix:II
Gender:M
Credentials:OD,FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15401 HARRIET ST
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-3069
Mailing Address - Country:US
Mailing Address - Phone:734-782-7200
Mailing Address - Fax:734-229-9558
Practice Address - Street 1:15401 HARRIET ST
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-3069
Practice Address - Country:US
Practice Address - Phone:734-782-7200
Practice Address - Fax:734-229-9558
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002266152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5006929Medicaid
MI5006929Medicaid
MI0E86509Medicare ID - Type Unspecified