Provider Demographics
NPI:1578561064
Name:WILDER, J EDWIN (MD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:EDWIN
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:PO BOX 928
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24063-0928
Mailing Address - Country:US
Mailing Address - Phone:540-953-0530
Mailing Address - Fax:540-953-0510
Practice Address - Street 1:840 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-7023
Practice Address - Country:US
Practice Address - Phone:540-953-0530
Practice Address - Fax:540-953-0510
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101047913207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB72848Medicare UPIN
VA00Y077B74Medicare PIN