MEDICARE: JODI WILDER D.O.

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	390200000X	Student in an Organized Health Care Education/Training Program		KY
2	207Q00000X	Family Medicine Physician	OS15990	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336696327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JODI WILDER D.O.

Provider Business Mailing Address
First Line	:	125 FLORIDA MEMORIAL PKWY STE 2200
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-9309
Country	:	US
Telephone Number	:	386-409-6839
Fax Number	:	386-409-6916

Provider Business Practice Location Address
First Line	:	125 FLORIDA MEMORIAL PKWY STE 2200
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-9309
Country	:	US
Telephone Number	:	386-409-6839
Fax Number	:	386-409-6916

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

Provider Enumeration Date	:	09/07/2016
Last Update Date	:	03/26/2021

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