Provider Demographics
NPI:1982996203
Name:CHARLES R WILDER OD PC
Entity Type:Organization
Organization Name:CHARLES R WILDER OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ROMEO
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:II
Authorized Official - Credentials:OD
Authorized Official - Phone:734-782-7200
Mailing Address - Street 1:15401 HARRIET ST
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-3069
Mailing Address - Country:US
Mailing Address - Phone:734-782-7200
Mailing Address - Fax:734-229-9558
Practice Address - Street 1:15401 HARRIET ST
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-3069
Practice Address - Country:US
Practice Address - Phone:734-782-7200
Practice Address - Fax:734-229-9558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002266251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5006929Medicaid
MI5006929Medicaid