MEDICARE: BRIAN CRANFORD WILDER 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	207R00000X	Internal Medicine Physician	022802	LA

General Provider Information

NPI Number	:	1558455733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN CRANFORD WILDER M.D.

Provider Business Mailing Address
First Line	:	501 DR MICHAEL DEBAKEY DR
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70601-5724
Country	:	US
Telephone Number	:	337-312-8360
Fax Number	:	337-312-6708

Provider Business Practice Location Address
First Line	:	1322 ELTON RD
Second Line	:	SUITE H
City	:	JENNINGS
State	:	LA
Zip	:	70546-4100
Country	:	US
Telephone Number	:	337-246-7200
Fax Number	:	337-246-7202

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	02/03/2017

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