Healthcare Provider Details

I. General information

NPI: 1164468443
Provider Name (Legal Business Name): MARINA SHIKHRIS WILDER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARINA S WILDER MD

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 WHITCHER ST NE SUITE 2150
MARIETTA GA
30060-1176
US

IV. Provider business mailing address

1341 CANTON RD SUITE A
MARIETTA GA
30066-6056
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-4268
  • Fax: 770-422-2950
Mailing address:
  • Phone: 770-422-0517
  • Fax: 678-638-7015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number042000
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number042000
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number42000
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: