Provider Demographics
NPI:1649644311
Name:WILDER, JOEY DARREN (DO)
Entity type:Individual
Prefix:DR
First Name:JOEY
Middle Name:DARREN
Last Name:WILDER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5535 S WILLIAMSON BLVD STE 700
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-8321
Mailing Address - Country:US
Mailing Address - Phone:386-231-6300
Mailing Address - Fax:
Practice Address - Street 1:5535 S WILLIAMSON BLVD STE 700
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-8321
Practice Address - Country:US
Practice Address - Phone:386-231-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-18
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY04358208M00000X
FLOS15971207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist