Provider Demographics
NPI:1982602173
Name:WILDER, JAMES L (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:L
Last Name:WILDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 MADISON OAK DR
Mailing Address - Street 2:STE # 570
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3943
Mailing Address - Country:US
Mailing Address - Phone:210-402-3700
Mailing Address - Fax:210-402-3892
Practice Address - Street 1:540 MADISON OAK DR
Practice Address - Street 2:STE # 570
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3943
Practice Address - Country:US
Practice Address - Phone:210-402-3700
Practice Address - Fax:210-402-3892
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL2750207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8S3030OtherBCBS PIN
TX8F1353Medicare PIN
TXG97371Medicare UPIN