Provider Demographics
NPI:1922667443
Name:WILDER, SHANE L (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:L
Last Name:WILDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7801 ACADEMY RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3379
Mailing Address - Country:US
Mailing Address - Phone:505-272-2700
Mailing Address - Fax:
Practice Address - Street 1:8700 BEVERLY BLVD STE 5512
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1804
Practice Address - Country:US
Practice Address - Phone:310-423-2811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-08
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2022-0910207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty