Provider Demographics
NPI:1598876385
Name:WILDE, JAMES A (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:A
Last Name:WILDE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1499 WALTON WAY
Mailing Address - Street 2:STE 1400
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2602
Mailing Address - Country:US
Mailing Address - Phone:706-724-6100
Mailing Address - Fax:706-722-5187
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-4951
Practice Address - Fax:706-721-7941
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-02-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA0460112080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG46011Medicaid
GA000797574AMedicaid
GA000797574AMedicaid
SCG46011Medicaid