Provider Demographics
NPI:1053374884
Name:WILDER, WILLIAM J (MD)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:J
Last Name:WILDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 PROFESSIONAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360
Mailing Address - Country:US
Mailing Address - Phone:985-868-1810
Mailing Address - Fax:985-876-3670
Practice Address - Street 1:12 PROFESSIONAL DRIVE
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360
Practice Address - Country:US
Practice Address - Phone:985-868-1810
Practice Address - Fax:985-876-3670
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA011220207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA119241Medicaid
B60666Medicare UPIN
5J955Medicare ID - Type Unspecified