Healthcare Provider Details

I. General information

NPI: 1255391066
Provider Name (Legal Business Name): ANNA L WILDERMUTH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3774 BAYLEY DR SUITE B
LAFAYETTE IN
47905-8651
US

IV. Provider business mailing address

PO BOX 4699
LAFAYETTE IN
47903-4699
US

V. Phone/Fax

Practice location:
  • Phone: 765-807-8180
  • Fax: 765-807-8181
Mailing address:
  • Phone: 765-449-2732
  • Fax: 765-449-1196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01043677A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: