Provider Demographics
NPI:1558398545
Name:WILDER, CHARLES C (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:C
Last Name:WILDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 E WEISGARBER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-2604
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:865-584-1363
Practice Address - Street 1:2240 SUTHERLAND AVE
Practice Address - Street 2:STE 104
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-2333
Practice Address - Country:US
Practice Address - Phone:865-909-0090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34381207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN110215562OtherRR MEDICARE PIN
TN3856361Medicaid
TN3856361Medicare ID - Type UnspecifiedLEGACY PIN
H19179Medicare UPIN
TN110215562OtherRR MEDICARE PIN