Healthcare Provider Details

I. General information

NPI: 1174513915
Provider Name (Legal Business Name): DEBRA L. WILDER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 CEDAR ST
KUTTAWA KY
42055-6287
US

IV. Provider business mailing address

PO BOX 370 91 CEDAR STREET
KUTTAWA KY
42055-0370
US

V. Phone/Fax

Practice location:
  • Phone: 270-388-7380
  • Fax: 270-388-7364
Mailing address:
  • Phone: 270-388-7380
  • Fax: 270-388-7364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number28168
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28168
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: