Healthcare Provider Details

I. General information

NPI: 1558398545
Provider Name (Legal Business Name): CHARLES C WILDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 05/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 SUTHERLAND AVE STE 104
KNOXVILLE TN
37919-2333
US

IV. Provider business mailing address

1225 E WEISGARBER RD SUITE 200
KNOXVILLE TN
37909-2604
US

V. Phone/Fax

Practice location:
  • Phone: 865-909-0090
  • Fax:
Mailing address:
  • Phone: 865-584-4747
  • Fax: 865-584-1363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34381
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: