Provider Demographics
NPI:1477692077
Name:WILDER, STEVEN TODD (DC)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:TODD
Last Name:WILDER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3224 MERCER UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-5663
Mailing Address - Country:US
Mailing Address - Phone:404-550-1891
Mailing Address - Fax:
Practice Address - Street 1:1540 HIGHWAY 138 SE
Practice Address - Street 2:SUITE 1B
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-1297
Practice Address - Country:US
Practice Address - Phone:770-761-2302
Practice Address - Fax:770-761-2303
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO05191111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA582132708OtherTAX ID NUMBER
GAU49925Medicare UPIN
GA582132708OtherTAX ID NUMBER