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NPI Code Detail

MEDICARE: DR. THEARON PAUL WILDER M.D.

MEDICARE: DR. THEARON PAUL 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
1207Q00000XFamily Medicine Physician15950KY

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1588661458
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. THEARON PAUL WILDER M.D.
Provider Business Mailing Address
First Line : PO BOX 1079
Second Line :
City : HENDERSON
State : KY
Zip : 42419-1079
Country : US
Telephone Number : 270-827-0353
Fax Number : 270-827-4966
Provider Business Practice Location Address
First Line : 1997 BARRETT CT
Second Line :
City : HENDERSON
State : KY
Zip : 42420-2667
Country : US
Telephone Number : 270-827-8662
Fax Number : 270-826-8220
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/06/2005
Last Update Date : 03/11/2013

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