Healthcare Provider Details

I. General information

NPI: 1528260247
Provider Name (Legal Business Name): WALTER B WILDSTEIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 COBB PKWY N SUITE 400
MARIETTA GA
30062-3581
US

IV. Provider business mailing address

720 COOL SPRINGS BLVD SUITE 300
FRANKLIN TN
37067-2626
US

V. Phone/Fax

Practice location:
  • Phone: 615-778-4066
  • Fax:
Mailing address:
  • Phone: 615-778-4066
  • Fax: 615-778-9114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number010394
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: