Provider Demographics
NPI:1639175524
Name:BUCKLEW-WILDER, PAMELA SUE (MD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:SUE
Last Name:BUCKLEW-WILDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 W MCCREIGHT AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-1842
Mailing Address - Country:US
Mailing Address - Phone:937-523-9820
Mailing Address - Fax:937-523-9829
Practice Address - Street 1:30 W MCCREIGHT AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-1842
Practice Address - Country:US
Practice Address - Phone:937-523-9820
Practice Address - Fax:937-523-9829
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35061787B208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0829278Medicaid
OHE22742Medicare UPIN
OHH105070Medicare PIN