MEDICARE: DR. JAMES OSCAR WILDE JR. M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	23852	OK
2	207Q00000X	Family Medicine Physician	22475	MS

General Provider Information

NPI Number	:	1003921172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES OSCAR WILDE JR. M.D.

Provider Business Mailing Address
First Line	:	201 S. MARKET ST.
Second Line	:
City	:	CHARLESTON
State	:	MS
Zip	:	38921
Country	:	US
Telephone Number	:	662-625-7118
Fax Number	:	662-647-8954

Provider Business Practice Location Address
First Line	:	201 S. MARKET ST.
Second Line	:
City	:	CHARLESTON
State	:	MS
Zip	:	38921
Country	:	US
Telephone Number	:	662-625-7118
Fax Number	:	662-647-8954

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	05/13/2014

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