Provider Demographics
NPI:1295712487
Name:WILDEMORE, JOHN K IV (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:K
Last Name:WILDEMORE
Suffix:IV
Gender:M
Credentials:MD
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Mailing Address - Street 1:744 W LANCASTER AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-2523
Mailing Address - Country:US
Mailing Address - Phone:610-688-8750
Mailing Address - Fax:610-688-8750
Practice Address - Street 1:744 W LANCASTER AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-2523
Practice Address - Country:US
Practice Address - Phone:610-688-8750
Practice Address - Fax:610-688-8751
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
PAMD423121207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H97261Medicare UPIN