Healthcare Provider Details

I. General information

NPI: 1083758056
Provider Name (Legal Business Name): GLORIA ANNONET WILDER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2516 SHERIDAN RD SE STE A
WASHINGTON DC
20020-5265
US

IV. Provider business mailing address

17956 SWANS CREEK LN
DUMFRIES VA
22026-4526
US

V. Phone/Fax

Practice location:
  • Phone: 202-610-6106
  • Fax: 202-610-6107
Mailing address:
  • Phone: 202-302-3996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101055487
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD21918
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: