Provider Demographics
NPI:1336696327
Name:WILDER, JODI (DO)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 FLORIDA MEMORIAL PKWY STE 2200
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-9309
Mailing Address - Country:US
Mailing Address - Phone:386-409-6839
Mailing Address - Fax:386-409-6916
Practice Address - Street 1:125 FLORIDA MEMORIAL PKWY STE 2200
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-9309
Practice Address - Country:US
Practice Address - Phone:386-409-6839
Practice Address - Fax:386-409-6916
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY390200000X
FLOS15990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program