Provider Demographics
NPI:1922021518
Name:WILDER, WALLACE S (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:S
Last Name:WILDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:210 SUNNYVIEW LN
Mailing Address - Street 2:SUITE 103
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3135
Mailing Address - Country:US
Mailing Address - Phone:406-752-8300
Mailing Address - Fax:406-752-3542
Practice Address - Street 1:210 SUNNYVIEW LN
Practice Address - Street 2:SUITE 103
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3135
Practice Address - Country:US
Practice Address - Phone:406-752-8300
Practice Address - Fax:406-752-3542
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MT3655208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0032344Medicaid
MT08110OtherBLUE CROSS
MT08110OtherBLUE CROSS