Healthcare Provider Details

I. General information

NPI: 1114114550
Provider Name (Legal Business Name): STEPHANIE KRESCH WILDER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 MARTIN LUTHER KING JR PKWY
SPRINGFIELD OR
97477-7514
US

IV. Provider business mailing address

PO BOX 70368
SPRINGFIELD OR
97475-0120
US

V. Phone/Fax

Practice location:
  • Phone: 541-868-9700
  • Fax: 541-485-7392
Mailing address:
  • Phone: 541-485-2777
  • Fax: 541-246-2353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number6360465-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberTP119
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD176904
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: