Provider Demographics
NPI:1902868565
Name:WILD, GARNER JOHNSON (MD)
Entity Type:Individual
Prefix:
First Name:GARNER
Middle Name:JOHNSON
Last Name:WILD
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:PO BOX 60371
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0371
Mailing Address - Country:US
Mailing Address - Phone:803-806-0080
Mailing Address - Fax:803-356-0668
Practice Address - Street 1:100 PALMETTO PARK BLVD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072
Practice Address - Country:US
Practice Address - Phone:803-806-0080
Practice Address - Fax:803-356-0668
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20350207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC203503Medicaid
H42572Medicare UPIN
SCH425721357Medicare PIN