Provider Demographics
NPI:1801982749
Name:WILDER, CAROL JEAN (MD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:JEAN
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:541-732-3650
Mailing Address - Fax:
Practice Address - Street 1:70 BOWER DRIVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501
Practice Address - Country:US
Practice Address - Phone:541-734-3650
Practice Address - Fax:206-368-6101
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00048866207Q00000X, 207QS0010X
HI10509207QS0010X
ORMD185352207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI49963303Medicaid