Healthcare Provider Details

I. General information

NPI: 1952490930
Provider Name (Legal Business Name): JAY SCOTT WILDER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 09/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 WISCONSIN AVE. WALTER REED NATIONAL MILITARY MEDICAL CTR
BETHESDA MD
20889-0001
US

IV. Provider business mailing address

8901 WISCONSIN AVE. WALTER REED NATIONAL MILITARY MEDICAL CTR
BETHESDA MD
20889-0001
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-0196
  • Fax: 301-319-4712
Mailing address:
  • Phone: 301-295-0196
  • Fax: 301-319-4712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD11743
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: