Provider Demographics
NPI:1760476774
Name:WILDER, DORIS LOUISE (MD)
Entity Type:Individual
Prefix:DR
First Name:DORIS
Middle Name:LOUISE
Last Name:WILDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DORIS
Other - Middle Name:LOUISE
Other - Last Name:TEMPLEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:907 18TH ST E STE 400
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3684
Mailing Address - Country:US
Mailing Address - Phone:229-353-3450
Mailing Address - Fax:229-353-6060
Practice Address - Street 1:1010 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:SYLVESTER
Practice Address - State:GA
Practice Address - Zip Code:31791-1900
Practice Address - Country:US
Practice Address - Phone:229-776-3500
Practice Address - Fax:229-777-8269
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056785207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08CBCCWOtherMEDICARE
GA068608997AMedicaid
GAHOSP29Medicare PIN
GAG25070Medicare UPIN