Healthcare Provider Details

I. General information

NPI: 1417195488
Provider Name (Legal Business Name): CAROL WILDER MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2009
Last Update Date: 02/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 MOHOULI ST
HILO HI
96720-4145
US

IV. Provider business mailing address

PO BOX 11148
HILO HI
96721-6148
US

V. Phone/Fax

Practice location:
  • Phone: 808-845-0728
  • Fax:
Mailing address:
  • Phone: 808-345-6976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number10509
License Number StateHI

VIII. Authorized Official

Name: DR. CAROL WILDER
Title or Position: PRESIDENT
Credential: MD
Phone: 808-345-6976