Provider Demographics
NPI:1821287483
Name:JAMES L WILDER MD PA
Entity Type:Organization
Organization Name:JAMES L WILDER MD PA
Other - Org Name:SOUTH TEXAS GYNECOLOGIC ONCOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LOWELL
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-402-3700
Mailing Address - Street 1:540 MADISON OAK DR
Mailing Address - Street 2:STE #570
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3943
Mailing Address - Country:US
Mailing Address - Phone:210-402-3700
Mailing Address - Fax:210-402-3892
Practice Address - Street 1:540 MADISON OAK DR
Practice Address - Street 2:STE #570
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3943
Practice Address - Country:US
Practice Address - Phone:210-402-3700
Practice Address - Fax:210-402-3892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0073MQOtherBCBS PIN
TX00653ZMedicare PIN