Provider Demographics
NPI:1023002763
Name:WILDE, STEPHEN WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:WILLIAM
Last Name:WILDE
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 1:700 SUNSET DR
Mailing Address - Street 2:SUITE 501
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2293
Mailing Address - Country:US
Mailing Address - Phone:706-208-0065
Mailing Address - Fax:706-549-8693
Practice Address - Street 1:700 SUNSET DR
Practice Address - Street 2:SUITE 501
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2293
Practice Address - Country:US
Practice Address - Phone:706-208-0065
Practice Address - Fax:706-459-8693
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033231207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00430372AMedicaid
GA279413OtherBCBS OF GA
GA10BDBDCMedicare ID - Type Unspecified
GAE68217Medicare UPIN