Provider Demographics
NPI:1891867909
Name:WILDS, ROBERT H (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:H
Last Name:WILDS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 WAPPOO CREEK DRIVE
Mailing Address - Street 2:SUITE 4B
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-2169
Mailing Address - Country:US
Mailing Address - Phone:843-795-7971
Mailing Address - Fax:
Practice Address - Street 1:105 WAPPOO CREEK DRIVE
Practice Address - Street 2:SUITE 4B
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-2169
Practice Address - Country:US
Practice Address - Phone:843-795-7971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1036152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD10361Medicaid
SC6193990001Medicare NSC
SCU52212Medicare UPIN
SCU522120281Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL