Provider Demographics
NPI:1396168753
Name:WILDER, AMETHYST (MD)
Entity type:Individual
Prefix:
First Name:AMETHYST
Middle Name:
Last Name:WILDER
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 1:1107 E 66TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-5701
Mailing Address - Country:US
Mailing Address - Phone:912-350-8404
Mailing Address - Fax:912-350-8067
Practice Address - Street 1:5 MALL ANX
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-4738
Practice Address - Country:US
Practice Address - Phone:912-721-8882
Practice Address - Fax:803-281-8882
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-21
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA078341207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty