MEDICARE: DR. JOHN JOSEPH WILDING D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	34003529W	OH

General Provider Information

NPI Number	:	1194720235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN JOSEPH WILDING D.O.

Provider Business Mailing Address
First Line	:	721 PLUM RIDGE TRL
Second Line	:
City	:	SIDNEY
State	:	OH
Zip	:	45365-1857
Country	:	US
Telephone Number	:	937-498-0788
Fax Number	:

Provider Business Practice Location Address
First Line	:	915 MICHIGAN ST
Second Line	:
City	:	SIDNEY
State	:	OH
Zip	:	45365-2401
Country	:	US
Telephone Number	:	937-492-8040
Fax Number	:	937-492-7447

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	07/09/2007

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