Provider Demographics
NPI:1770753568
Name:WILDRIDGE, JEFFREY A (OD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:WILDRIDGE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:388 E HIGHWAY 67
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75137-4159
Mailing Address - Country:US
Mailing Address - Phone:972-296-2020
Mailing Address - Fax:972-296-0992
Practice Address - Street 1:388 E HIGHWAY 67
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75137-4159
Practice Address - Country:US
Practice Address - Phone:972-296-2020
Practice Address - Fax:972-296-0992
Is Sole Proprietor?:No
Enumeration Date:2008-03-07
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX03861TG207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology