Healthcare Provider Details

I. General information

NPI: 1154393791
Provider Name (Legal Business Name): THOMAS OLIVER WILDES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 12/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

962 PARKLAND DR
CHIPPEWA FALLS WI
54729-5084
US

IV. Provider business mailing address

962 PARKLAND DR
CHIPPEWA FALLS WI
54729-5084
US

V. Phone/Fax

Practice location:
  • Phone: 608-345-3677
  • Fax:
Mailing address:
  • Phone: 608-345-3677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number26197-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: