Provider Demographics
NPI:1558455733
Name:WILDER, BRIAN CRANFORD (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CRANFORD
Last Name:WILDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:501 DR MICHAEL DEBAKEY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5724
Mailing Address - Country:US
Mailing Address - Phone:337-312-8360
Mailing Address - Fax:337-312-6708
Practice Address - Street 1:1322 ELTON RD
Practice Address - Street 2:SUITE H
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546-4100
Practice Address - Country:US
Practice Address - Phone:337-246-7200
Practice Address - Fax:337-246-7202
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA022802207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G81461Medicare UPIN
LA370282YH5NMedicare PIN
LAP01388277Medicare PIN