Provider Demographics
NPI:1659592152
Name:WILDES, TANYA MARYA (MD)
Entity Type:Individual
Prefix:DR
First Name:TANYA
Middle Name:MARYA
Last Name:WILDES
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8056
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-747-1171
Mailing Address - Fax:314-362-3192
Practice Address - Street 1:150 ENTRANCE WAY
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1645
Practice Address - Country:US
Practice Address - Phone:636-996-3360
Practice Address - Fax:636-916-9176
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2018-01-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2009005695207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILENROLLEDMedicaid
MO1659592152Medicaid