Provider Demographics
NPI:1588661458
Name:WILDER, THEARON PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:THEARON
Middle Name:PAUL
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 1079
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42419-1079
Mailing Address - Country:US
Mailing Address - Phone:270-827-0353
Mailing Address - Fax:270-827-4966
Practice Address - Street 1:1997 BARRETT CT
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2667
Practice Address - Country:US
Practice Address - Phone:270-827-8662
Practice Address - Fax:270-826-8220
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15950207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64159502Medicaid
KY64159502Medicaid
KY1310701Medicare ID - Type Unspecified