MEDICARE: DR. JOHN K WILDEMORE IV M.D.

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	207N00000X	Dermatology Physician	MD423121	PA

General Provider Information

NPI Number	:	1295712487
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN K WILDEMORE IV M.D.

Provider Business Mailing Address
First Line	:	744 W LANCASTER AVE
Second Line	:	SUITE 230
City	:	WAYNE
State	:	PA
Zip	:	19087-2523
Country	:	US
Telephone Number	:	610-688-8750
Fax Number	:	610-688-8750

Provider Business Practice Location Address
First Line	:	744 W LANCASTER AVE
Second Line	:	SUITE 230
City	:	WAYNE
State	:	PA
Zip	:	19087-2523
Country	:	US
Telephone Number	:	610-688-8750
Fax Number	:	610-688-8751

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

Provider Enumeration Date	:	12/28/2005
Last Update Date	:	07/08/2007

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