Healthcare Provider Details

I. General information

NPI: 1083976971
Provider Name (Legal Business Name): ELIJAH WILDER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41877 ENTERPRISE CIR N STE 200
TEMECULA CA
92590-5628
US

IV. Provider business mailing address

PO BOX 636256 CENTRAL CREDENTIALING ML 806
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 909-755-0585
  • Fax: 951-228-9267
Mailing address:
  • Phone: 513-585-5508
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number02006180A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A22919
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number34012700
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number04444
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: