Healthcare Provider Details

I. General information

NPI: 1003921172
Provider Name (Legal Business Name): JAMES OSCAR WILDE JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 05/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S. MARKET ST.
CHARLESTON MS
38921
US

IV. Provider business mailing address

201 S. MARKET ST.
CHARLESTON MS
38921
US

V. Phone/Fax

Practice location:
  • Phone: 662-625-7118
  • Fax: 662-647-8954
Mailing address:
  • Phone: 662-625-7118
  • Fax: 662-647-8954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23852
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22475
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: