Healthcare Provider Details

I. General information

NPI: 1164490611
Provider Name (Legal Business Name): JEFFREY W WILDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7985 S MACKINAW TRL
CADILLAC MI
49601-8111
US

IV. Provider business mailing address

1105 SIXTH ST
TRAVERSE CITY MI
49684-2345
US

V. Phone/Fax

Practice location:
  • Phone: 231-876-7200
  • Fax:
Mailing address:
  • Phone: 231-876-7200
  • Fax: 231-547-8088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number65787
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301067907
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: