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General NPI Number Information
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NPI Number | 1487863858
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Entity Type | Individual
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Provider Name | BERNADETTE MARIA MANDES WILDEMORE MD
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Gender | Female
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Dates
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Enumeration Date | 05/22/2007
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Last Update Date | 06/20/2014
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Provider Practice Location Address
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Address Line | 134 ANSLEY DR STE 500
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City | DAHLONEGA
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State | GA
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Zip | 30533-1641
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Country | US
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Telephone | 678-853-2419
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Fax |
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Provider Business Mailing Address
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Address Line | 4405 ROSEMAN TRL
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City | CUMMING
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State | GA
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Zip | 30040-9367
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Country | US
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Telephone | 215-609-7472
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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License Number | MD430740
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 2013-02274
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 70607
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License Number State | GA
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Taxonomy #4
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MD.33137
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License Number State | AL
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Taxonomy #5
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MD430740
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License Number State | PA
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Taxonomy #6
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MD36443
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License Number State | SC
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Taxonomy #7
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 242668
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License Number State | MA
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Taxonomy #8
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MD50706
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License Number State | TN
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