Healthcare Provider Details

I. General information

NPI: 1982996203
Provider Name (Legal Business Name): CHARLES R WILDER OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 05/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15401 HARRIET ST
ROMULUS MI
48174-3069
US

IV. Provider business mailing address

15401 HARRIET ST
ROMULUS MI
48174-3069
US

V. Phone/Fax

Practice location:
  • Phone: 734-782-7200
  • Fax: 734-229-9558
Mailing address:
  • Phone: 734-782-7200
  • Fax: 734-229-9558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number4901002266
License Number StateMI

VIII. Authorized Official

Name: DR. CHARLES ROMEO WILDER II
Title or Position: PRESIDENT
Credential: OD
Phone: 734-782-7200