Healthcare Provider Details

I. General information

NPI: 1982602173
Provider Name (Legal Business Name): JAMES L WILDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 06/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 MADISON OAK DR STE # 570
SAN ANTONIO TX
78258-3943
US

IV. Provider business mailing address

540 MADISON OAK DR STE # 570
SAN ANTONIO TX
78258-3943
US

V. Phone/Fax

Practice location:
  • Phone: 210-402-3700
  • Fax: 210-402-3892
Mailing address:
  • Phone: 210-402-3700
  • Fax: 210-402-3892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberL2750
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: