Provider Demographics
NPI:1487863858
Name:WILDEMORE, BERNADETTE MARIA MANDES (MD)
Entity Type:Individual
Prefix:DR
First Name:BERNADETTE
Middle Name:MARIA MANDES
Last Name:WILDEMORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4405 ROSEMAN TRL
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-9367
Mailing Address - Country:US
Mailing Address - Phone:215-609-7472
Mailing Address - Fax:
Practice Address - Street 1:134 ANSLEY DR STE 500
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-1641
Practice Address - Country:US
Practice Address - Phone:678-853-2419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD430740207ZP0102X, 174400000X
NC2013-02274174400000X
GA70607174400000X
ALMD.33137174400000X
SCMD36443174400000X
MA242668174400000X
TNMD50706174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No174400000XOther Service ProvidersSpecialist