Provider Demographics
NPI:1265543359
Name:WILDY, KATHRYN S (MD)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:S
Last Name:WILDY
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 1:2725 S 144TH ST STE 212
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-5253
Mailing Address - Country:US
Mailing Address - Phone:402-637-0800
Mailing Address - Fax:402-637-0808
Practice Address - Street 1:2727 S 144TH ST STE 240
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-5201
Practice Address - Country:US
Practice Address - Phone:402-609-1200
Practice Address - Fax:402-609-1220
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA35647207RR0500X
NE22818207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0580225Medicaid
NE30703OtherBCBSN
IA1580225Medicaid
NE10025793100Medicaid
NE47068731713Medicaid
NE47068731720Medicaid
NE47068731713Medicaid
NE47068731720Medicaid
IA12356Medicare ID - Type Unspecified
IA1580225Medicaid