MEDICARE: DR. JEROME WILDES 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	207KA0200X	Allergy Physician	081878	NY

General Provider Information

NPI Number	:	1619961539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEROME WILDES M.D

Provider Business Mailing Address
First Line	:	222 BROADWAY
Second Line	:
City	:	LAWRENCE
State	:	NY
Zip	:	11559-1502
Country	:	US
Telephone Number	:	516-371-6745
Fax Number	:	516-239-3743

Provider Business Practice Location Address
First Line	:	9116 158TH AVE
Second Line	:
City	:	HOWARD BEACH
State	:	NY
Zip	:	11414-3126
Country	:	US
Telephone Number	:	718-835-3454
Fax Number	:	516-239-3743

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

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	11/05/2021

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