Healthcare Provider Details

I. General information

NPI: 1760476774
Provider Name (Legal Business Name): DORIS LOUISE WILDER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DORIS LOUISE TEMPLEMAN MD

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W FRANKLIN ST
SYLVESTER GA
31791-1900
US

IV. Provider business mailing address

907 18TH ST E STE 400
TIFTON GA
31794-3684
US

V. Phone/Fax

Practice location:
  • Phone: 229-776-3500
  • Fax: 229-777-8269
Mailing address:
  • Phone: 229-353-3450
  • Fax: 229-353-6060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number056785
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: