Provider Demographics
NPI:1598854663
Name:WILDER, ALFRED CHRISTIAN (MD)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:CHRISTIAN
Last Name:WILDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:FRED
Other - Middle Name:
Other - Last Name:WILDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3405 WANDERING MDWS
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-1650
Mailing Address - Country:US
Mailing Address - Phone:512-695-7005
Mailing Address - Fax:512-459-1251
Practice Address - Street 1:3405 WANDERING MDWS
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-1650
Practice Address - Country:US
Practice Address - Phone:512-695-7005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0353208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110122201Medicaid
B27579Medicare UPIN