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General NPI Number Information
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NPI Number | 1548397821
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Entity Type | Individual
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Provider Name | DEREK L WILDER O.D.
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Gender | Male
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Dates
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Enumeration Date | 02/27/2007
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Last Update Date | 01/29/2021
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Provider Practice Location Address
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Address Line | 11310 BEACH CHANNEL DR
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City | ROCKAWAY PARK
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State | NY
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Zip | 11694-2209
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Country | US
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Telephone | 718-474-1234
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Fax | 718-945-5809
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Provider Business Mailing Address
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Address Line | 4000 POPLAR LEVEL RD
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City | LOUISVILLE
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State | KY
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Zip | 40213-1524
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Country | US
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Telephone | 502-813-8923
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Fax | 502-451-8663
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1704DT
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License Number State | KY
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